Endotracheal tube care in PICU

Key points

Endotracheal tube procedures including changing tapes, open suction, and extubation require a minimum of two people.

• ETT suctioning should only be performed as clinically indicated, not as a routine intervention.

• There is no evidence to support routine instillation of 0.9% saline during ETT suction.

• Closed, inline suction should be used for children who require droplet or airborne precautions for respiratory infections.
  

Introduction

An ETT is the most common artificial airway used for short-term airway management or mechanical ventilation. The tube may be inserted either nasally or orally and may be un-cuffed or cuffed. The goals when caring for a patient with an ETT are to ensure that the tube remains secure and patent, does not cause a pressure injury, and that infection is prevented. A patient who has an ETT in situ is nil by mouth and their calorific needs are met by enteral tube feeds or total parenteral nutrition (TPN).

Intubation

Insertion of an ETT is a medical responsibility. Nursing staff assist the medical team with ETT placement. Prior to intubation the nurse should gather the required equipment and set up the ventilator with the appropriate patient weight, ventilation settings and ensure that checks have been performed. Refer to the emergency intubation guideline for more information.

The ETT position is verified using end tidal CO₂ monitoring, or a PediCap if this is not immediately available. The chest should be visually assessed for bilateral synchronous chest movement and auscultated to detect bilateral air entry. The ETT should be secured with silk and tapes as per the instructions below. A chest X-ray should be performed to confirm correct placement.

Document in the patient’s clinical record:

• ETT size

• Internal length (at nares/lips)

• ETT cuffed or uncuffed

ETT security

Security of the ETT should be assessed hourly and tapes replaced as required/when loose. Reinforcing tapes is not an acceptable substitute for replacing loose tapes. Children who are clinically unstable, have a critical airway or high risk cardiac patients should have their ETT re-taped during daytime hours when senior medical support is available.

Re-taping an Endotracheal Tube (ETT)

Re-taping always requires a minimum of two people. The first person holds the patient’s head and ETT, ensuring the airway is secure throughout the procedure. The second person replaces the tapes. A third person may sometimes be required to assist with safe holding.

The procedure should be explained to the child and the family.

A call on the intercom system advising that you are “re-taping in bedspace (2A)” should be completed. This ensures that medical and senior nursing staff are aware of the procedure and available to assist if required.

Consider what other procedures may be happening at the time and delay re-tape if required and until senior support if available.

Consider temporarily increasing the Fi0₂ if the patient is prone to desaturation on handling or has a lot of secretions. Restrain the child appropriately by wrapping, using arm splints or safe holding techniques.

Sedation may be required if the child is unable to be safely immobilised with the above techniques but should not be used as a routine for every patient. Muscle relaxant is indicated for children with critical airways or severe pulmonary hypertension.

Equipment required

• Resuscitation trolley at bedside with a spare ETT the same size as the patient’s

• Two lengths of 2.5cm leucoplast cut into ‘trouser legs’

• Length of black silk

• Protective barrier wipe

• Gauze and normal saline to clean

• Scissors

• Sedation and/or paralysis as required

Nasal ETT procedure

Oral ETT procedure

Coloured tapes have been used to highlight the procedure. Brown leucoplast tape is used
in the clinical setting.

1. Use silk to mark the length of the ETT at the lip. Make sure the silk is not so tight that it cuts into the lip.
   

   

2. Apply the first tape from the top of the patient’s cheek on the same side the ETT is situated. Wrap around the ETT once and over the top lip. Position the ETT so it doesn’t press too firmly on the corner of the mouth to minimise pressure.
   

   

3. Apply the second tape along the bottom of the cheek on the same side as the ETT, around the ETT once and across the chin. Ensure the tapes run parallel to each other.
   

   

4. Apply two more strips of tape straight across the top lip and chin.
   

Oral ETT securing device

Use of a securing device should be considered for any oral ETT size 5.0 or larger that is likely to remain in situ for more than 24 hours. The benefits of using a securing device are that the ETT can be moved more frequently to relieve pressure.

If considering using an ‘oral securing device with integrated bite guard’, exert precaution with patients who have loose teeth, dental appliances and facial swelling/oedema as the exertion of pressure may cause dermal injury and dental damage (associated with biting). Further precautions are listed in product information leaflet.

To minimise the risk of pressure injuries, inspect the patient’s lips, skin and oral cavity at the time of mouth cares (2 - 4 hourly) and reposition the tube.

For instructions for use, please refer to product information leaflet.

Suctioning

The goal of suctioning is to maximise the amount of secretions removed with minimal adverse effects. Correct suctioning improves gas exchange, decreases airway pressure and improves oxygenation. The risks of suctioning include atelectasis, tracheal mucosal injury, hypoxia and haemodynamic instability. Suctioning should therefore not be performed as a routine intervention, but rather as indicated after a thorough clinical assessment.

Assessing the need for suctioning

Endotracheal suctioning should be performed only when clinically indicated:

• Visible secretions in the airway

• When airway patency is questioned

• Increased respiratory rate, sustained coughing or both

• Clinically apparent increased work of breathing

• Decreased oxygen saturations from patient’s baseline

• Coarse breath sounds by auscultation

• Increased peak inspiratory pressure during volume controlled ventilation

• Decreased tidal volume during pressure controlled ventilation

• Sawtooth pattern on a flow-volume loop
  

Suction catheter size

Choosing the correct size suction catheter minimizes the risk of atelectasis (catheter too large) or insufficient secretion clearance (catheter too small). Choose a size that is no more than double the internal diameter of the endotracheal tube in situ.

Shallow vs Deep suction

Shallow suction is usual method of suctioning to effectively clear secretions and minimise trauma. The catheter is inserted into the ETT at a predetermined depth (total length of ETT plus adapter). Deep suction, where the catheter is inserted until resistance is met at the carina, is known to cause trauma to the tracheal mucosa and should not be routinely performed.

Open vs In-line (closed) suction

Open suction refers to disconnecting the patient from the ventilator and inserting a suction catheter directly into the ETT.

In-line suction systems allow suctioning without disconnecting the patient from the ventilator. In-line suction systems allow for suctioning to be performed without the assistance of a second person and may offer increased infection prevention for staff. In-line suction has been shown to preserve end expiratory lung volumes, however there is minimal difference between open and closed suctioning in regard to oxygenation and incidence of VAP.

In-line suction systems should be used for patients in PICU who require droplet or airborne precautions for respiratory infections, either in a single room or cohorted with other patients. They should also be considered for severely PEEP dependent patients and those who do not tolerate hand ventilation well.

A Bodai swivel connector may be considered for patients who require frequent suctioning, as it allows a suction catheter to be passed without disconnecting from the ventilator. Suctioning through a Bodai connector may also be performed without the assistance of a second person if the patient is stable.

Setting up in-line suction

ETT size 5.0 or smaller

Remove the ETT end and replace with the in-line suction connector. Use the same sized suction catheter that you would normally.

Make sure you have the correct size connector.

Put the ETT end in a labelled specimen bag and hang at the bedside

ETT size 5.5 or larger

In-line suction will connect directly onto ETT

In-line suction catheters should be changed every 72 hours. Label clearly with date and time suction catheter was changed.

Normal saline instillation

The practice of instilling 0.9% sodium chloride into the ETT prior to suctioning should not be routine. There is no evidence that it improves outcomes, and some evidence to suggest it could be harmful. Secretion removal can be facilitated by correct humidification, adequate nutrition, and effective mobilisation of the patient. Normal saline may be considered for thick tenacious secretions.

If required, the following volumes of saline should be used:

• 0.25 mL - 0.5 mL for an infant < 5 kg

• 1 - 2 mL for a child 5 kg - 30 kg

• 2 - 5 mL for a larger child > 30 kg

Preoxygenation

Patients should be pre-oxygenated prior to suctioning by using the suction function button on the ventilator.

Preoxygenation is clinically contraindicated in patients with single ventricle or duct dependent cardiac anatomy. The T-piece must be connected to blended oxygen at the same concentration as on ventilator for manual breaths.

During disconnection from the ventilator and between open suctioning, the second person should deliver effective manual breaths via the anaesthetic T-piece. A patient who is intubated but not ventilated should receive CPAP via the T-piece unless they require breaths to assist with lung re-inflation.

Open suction

Equipment required

• Functioning suction apparatus with tubing, set to a maximum negative pressure of 100 - 120 mmHg

• Oxygen source/blender

• An inline manometer if:

  • weight less than 2.5 kg

  • lung hypoplasia including congenital diaphragmatic hernia

  • recent airway surgery

  • potential or actual air leak syndromes

• Suction catheters of appropriate size.

• Non-sterile gloves

• Disposable plastic apron

• Face mask and eye protective glasses

• Normal saline for flushing suction tubing after procedure

Procedure

In-line suction

Equipment required

• Appropriate-size in-line suction catheter connected to ETT

• Functioning suction apparatus with tubing

• Non-sterile gloves and plastic apron

• Syringe of 0.9% sodium chloride to flush tubing

Procedure

Nursing considerations

• Change the suction liner and patient tubing when full, on discharge, or after seven days

• Allow 20-30 minutes before taking blood gas to ensure an accurate sample.

Endotracheal tube cuff care

Whenever a patient has a cuffed endotracheal tube in situ it is important to ensure that the cuff pressure is maintained at a safe level to promote optimal ventilation and prevent iatrogenic complications. High cuff pressures can cause pressure necrosis and result in long term tracheal stenosis.

Cuff pressure should be checked every four hours using a manometer and the cuff pressure documented on PICU flowchart. Ensure the cuff pressure is enough to prevent a leak but no greater than 20cmH₂O. Suction the oropharynx before checking the pressure as the cuff will often deflate during this process.

Extubation

Extubation is generally nurse led and follows the decision by the medical and nursing team that the patient is ready to have their ETT removed.

Extubation is always a two person procedure.

Senior nursing (clinical charge nurse/shift coordinator) and medical staff are to be informed and easily accessible within the unit.

A child who has been identified as a high risk for 'failed extubation' should be extubated with medical staff in attendance at the bedside. Consider having nebulised adrenaline and re-intubation medication and equipment prepared.

Nasogastric feeds must be withheld for four hours prior to extubation. Nasojejeunal feeds are only temporarily stopped during the actual extubation procedure.

Equipment required:

• Resuscitation trolley at the bedside

• Anaesthetic T-piece and mask

• Nasal prongs or non-invasive ventilation system as required

• Syringe to deflate cuff

• Remove wipes and cloths to clean face of residual plaster

• Suction equipment with appropriate sized catheters and yankauer

Procedure