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endotracheal tube fixation

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  Endotracheal tube has been used to ventilate millions of people for almost fifty years but stabilizing tube has always been a major problem. We intubate babies and adults during surgical procedure and during resuscitation. We have seen various methods recommended and tried but non have addressed all the issues.

Various reports of accidental extubation appeared in the medical literature. Some anaesthetists and intensivists adopted to use nasal intubation. We have seen more problems and complications reported due to nasal intubation yet stability is the only argument favouring nasal intubation.

We have tested various methods, observed babies behaviour and developed the method of fixation. Adult and children find nasal intubation very uncomfortable and Prefer to tolerate soggy gauze and excess salivation.

We have included photographs to explain the problem and suggested alternatives. We have used DIY methods, sticky tapes, clamps and gauze - let us change and make babies (and hopefully adults) life comfortable when staying alive with the help of ventilator. There is more problems you should be worried about than just stability.

   Endotracheal tubes at present are stabilised using gauze and tapes. This must be very uncomfortable for patients and the relatives. Oral secretions moisten the gauze and make produces pressure necrosis at the angle of the mouth. At times the oral secretions dry up due to the effect of drugs. I feel it must be painful and very uncomfortable to patients who ar critically ill.  

         

  In Paediatric intensive and neonatal care the problem is spontaneous extubation (tube falling out). This happens because babies and children cannot understand the importance of endotracheal tube. They are active and will physically remove the tube when it becomes uncomfortable. Due to this danger the tube are firmly fixed using retainers. At times the babies hand used to be tied using a gauze.  
Mouth sealed off       Excess salivation

  Firm fixation results in distorted face, trauma to the angle of mouth. Babies unable to open their mouth and move the tongue around will be not helpful in future development. Psychologists explain that babies communicate using smell and mouth. Imagine the frustration of these babies

Babies try hard to move the endotracheal tube towards the angle of their mouth. Tube staying on the angle is probably comfortable, as they can move their tongue and also reduce palatal grove

  

DIY tube holder       Distorted face

  Endotracheal tube holder stabilizing the tube in the angle of the mouth is comfortable. This should reduce the incidence of palatal grove and delay in developing speech. The mouth can be opened and tongue moved about will help salivary secretion to drip out comfortably.

Babies can also suck dummy and feel contented (helps future psychological development)

  

Tube at the angle of mouth   Intufix   Tube holder on upper lip

  The tube holder should be versatile, able to change the location of placing it on the face. This is because babies may need surgical procedure performed - like dental or gum surgery, nasal, upper lip surgery (cleft lips).  

Tube holder placed on chin       Tube pulled out to with holder to demonstrate stability
  Some nurses and doctors find it uncomfortable if the tube holder move. Using hydrogel tapes to prevent holder moving could help to relieve anxiety (as time pass by you may start trusting the holder to do the job).

While changing endotracheal tube - please leave the holder attached to the bonnet of the baby - you can use the holder to fix the new tube.

  

Hydrogel tape to stabilize       Heatsheild tape to help stabilise
   
         

Methods of Endotracheal Tube fixation (Published in Medical Journals & Text Books)

Thanks to all the authors of these publications : They have thought of this problem and made some effort to find salutions. I acknowledge their contribution

Ref :

Ref :Text Book of Neonatology by Roberton

Ref : Text Book of Neonatology by Roberton

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Ref :

Ref :

Ref :

Ref :

Ref : Sick New Born Baby, Dr David Harvey

Ref : Anaesthesia Analgesia, KM Srivatsa [ intufix® ]

CAN WE JUSTIFY NASAL INTUBATION IN CHILDREN ?

By : Dr Kadiyali M Srivatsa

Intubation and ventilation of neonates was initially introduced in 1962. Neonatologists around the world have now mastered the technique resulting in very pre-term neonates surviving to adulthood. Mortality has decreased but morbidity seems to be on the increase. The aim of this annotation is to help decrease morbidity by reducing some factors which contribute.

The WHO definition of health is "Physical and mental well being of a person". Most of our studies have been focused on the physical aspect of development. This is because the signs are obvious and can be easily addressed. Psychological and mental developmental assessments are not so clear and cannot be tested and are time consuming. Our aim must be to help a neonate survive as well as develop into a healthy productive individual. They are not to become a burden on society as such. This can be traumatic to the parents and the people who care for such children. Ten years ago when I started working in the neonatal unit, my aim was to to intubate, resuscitate and cannulate fast and efficiently. The joy of success pushed my ego to very high boundaries. I almost thought that I was the best and did not think that I was dealing with small fragile infants who one day will grow up to be an adult. These individuals were subjected to traumatic procedures because there were no alternatives. This happens even today and no one talks about them.

I recently met an individual who is being treated for depression by a psychiatrist. He is thirty years old, and was said to have been born pre-term. The mother explained to me that he was one of the earliest babies to have been on a respirator." He was almost dead", she explained. His heart beat had stopped for almost thirty minutes, and it was said a miracle he survived. Both parents are very loving and well off. He had the best education, good social up bringing and educated yet stays at home doing nothing constructive. This person came across as if he had given up hope to live and was not making any effort to take up the challenges of life. This reminded me of Seligmans theory of learned helplessness.

When I discussed about the Seligman’s theory with his mother, she confessed that her son had always lacked confidence and gave up very easily. It did look as if he was helpless and was not ready to put up a fight and acquire what he intend to achieve. Froyed stated that the psychological development of an individual develops in the first six weeks of life. This person who was traumatised as a neonate and almost died was left with a dent in his psychological development.

We all know that pre term infants cared for in neonatal care units are not bonding well to their parents. The incidence of non accidental injury is higher when compared to the infants born normally.

Psychologists have in fact proved that a baby recognises its mother by smell, and bonding is better if the baby feels secure in a comfortable environment.

Children born in a developing countries bond well to their parents. These parents cannot offered to feed their infants adequately, but they always cuddle and comfort their infants until the infant can crawl on their own. Most are breast fed until another child is born or till the breast milk dries up.

What happens in the neonatal unit which could hamper bonding with the mother and damage infants psychologically ?. The infants are locked up in the incubators, their nostrils are blocked with endotracheal and the nasogastric tubes. At times the baby open his eyes and looks at an artificial steamy environment. He cannot smell and unable to move about because the hand are tied up or paralysed by neuromuscular blocking drugs. All these exercise is mainly because we are scared to let the endotracheal tube fall out, or the cannula to be dislodged. Is this so important ?

Most babies who fight and struggle are mainly because of anoxia and not because they are feeling uncomfortable with the tubes stuck up through their nostrils. This is rarely recognised as the oxygen saturation is maintained. We have to remember that protective mechanisms operating will maintain the saturation to fascilitate more oxygen delivery to the brain. The effect on peripheral tissue will be compromised. Oxygen will be firmly bound to the red cells but will not be released it into the tissue. The over activity of the baby does utilise more glucose, compromising brain of its only food. When the babies are ventilated initially they do have more foetal haemoglobin, well known for its affinity to oxygen. This leads us to believe the baby is fine, as he is maintaining the saturation. At times when the saturation drops, we blame the baby who is fighting and crying.

Now I feel we should justify our actions and discuss openly how to do away with some long term myths and habits. This could result in better quality of life in the neonates whom we have helped to survive. The contributing factors usually associated with the neonates must be discussed.

  OTHER PROBLEMS WITH NASAL INTUBATION
INFECTION Bacterial sinusitis is recognised as a complication of prolonged nasotracheal intubation.
  Ref : V. Forsum U. Lundgren J. Possible errors in diagnosis of bacterial sinusitis in tracheal intubated. Acta Anaesthesiologica Scandinavica. 38(7):699-703, 1994 Oct.
  Nosocomial sinusitis is a complication of endotracheal and mechanical ventilation in critically ill patients. Its incidence is often underestimated because of a lack of clinical signs. It is suspected in patients with nasal discharge or unexplained fever. Its incidence varies greatly according to diagnostic criteria and the population studied. Infectious sinusitis is less frequent than noninfectious sinusitis, occurring in 20 to 30% of patients intubated for at least seven days. Risk factors for RMS were nasal placement and duration of endotracheal and gastric intubation.
  Ref: Bert F.. Lambert-Zechovsky N. Sinusitis in mechanically ventilated patients and its role in the pathogenesis of nosocomial pneumonia. [Review] [84 refs]. European Journal of Clinical Microbiology & Infectious Diseases. 15(7):533-44, 1996 Jul.)
  Rouby JJ. Laurent P. Gosnach M. Cambau E. Lamas G. Zouaoui A. Leguillou JL. Bodin L. Khac TD. Marsault C. et al. Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. American Journal of Respiratory & Critical Care Medicine. 150(3):776-83, 1994 Sep.)
TRAUMA Endotracheal intubation of a preterm infant cadaver was performed both orally and nasally to assess the relative movement of the endotracheal tube with changes in head position. The results indicate slightly increased movement of the nasotracheal tube with flexion and rotation, and markedly increased movement with extension. The possible relationship between tube movement and the development of subglottic stenosis
  Ref : (DDonn SM. Blane CE Endotracheal tube movement in the preterm neonate: oral versus nasal intubation. Annals of Otology, Rhinology & Laryngology. 94(1 Pt 1):18-20, 1985
  Massive bleeding occurred while intubating nasally resulting in difficulty to ventilate the patient by face mask and conventional endotracheal intubation by laryngoscopy
  Ref: Kulozik U. Georgi R. Krier C. Intubation with the Combitube-TM in massive hemorrhage from the locus Kieselbachii. [German]. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie. 31(3):191-3, 1996 Apr
  Eighty patients having anaesthesia for oral surgery requiring nasal intubation were randomly allocated to be intubated with either a plain Magill red rubber or cuffed polyethylene endotracheal tube and in a double blind manner, to receive xylometazoline 0.1% vasoconstrictor nasal spray. The extent of any epistaxis occurring was assessed by an independent observer. With the Magill tube there was bleeding in one out of twenty patients in both the vasoconstrictor group and non vasoconstrictor group at intubation and no bleeding in either of the two groups at extubation. With the polyethylene tube sixteen out of twenty patients had bleeding in the non vasoconstrictor group. This improved to seven out of twenty with the administration of vasoconstrictor drops at intubation (chi square 10.2; p < 0.01) in the polyethylene tube group. At extubation ten out of twenty patients had bleeding in the non vasoconstrictor group improving to two out of twenty with the administration of the vasoconstrictor (chi square 9.6; p,0.01). The use of the vasoconstrictor xylometazoline helped to reduce epistaxis that occurred during nasal intubation and further study into the type of endotracheal tube is recommended.
  Ref: O'Hanlon J. Harper KW. Epistaxis and nasotracheal intubation--prevention with vasoconstrictor. Irish Journal of Medical Science. 163(2):58-60, 1994 Feb.
  Laryngoscopy causes temporary postoperative dysfunction of the (TMJ): during iatrogenic TMJ manipulation in anaesthetised patients, the TMJs have lost the protection afforded by the tone of the surrounding muscles. Thus far, the exact type and extent of TMJ movements have not been known. Lipp M et al visualise and assessed temporomandibular joint movements during intubation by means of electronic axiography, a diagnostic monitor of TMJ movements used in dentistry: Intubation was performed 100 s after injection of the relaxant. Pre- and postoperatively (every 24 h over 3 days, in case of positive findings longer) recorded were: active movements of the mandible (maximal mouth opening/ max. laterotrusion); dysfunction of the TMJ; and pain sensation in the TMJ (Helkimo rating). MOTs and EITs were recorded and analysed with the system described and typical EIT patterns were identified: bland, clinically uneventful intubations (n = 7), massive distraction and laterotrusion of the EIT compared to the MOT (n = 24), and blocked or limited TMJ movements resulting in intubation problems (n = 1). Routes, and instruments for intubation as well as to evaluate potential traumatising movements during endotracheal intubation.
  Lipp M. Daublander M. Thierbach A. Reuss U. Movement of the temporomandibular joint during tracheal intubation. [German]. Anaesthesist. 45(10):907-22, 1996 Oct.
NASAL PRONGS USED TO AVOID VENTILATION Prolonged endotracheal intubation has become the standard of care in most neonatal units for maintenance of mechanical ventilation in the presence of respiratory distress. Unfortunately this approach has become associated with significant complications, including acquired subglottic stenosis. We have successfully used nasal continuous positive airway pressure to avoid or decrease the incidence and duration of endotracheal intubation. With use of this technique we have been able to significantly reduce sequelae (i.e., bronchopulmonary dysplasia, chronic lung disease, intraventricular hemorrhage) and have not encountered subglottic stenosis in more than 200 cases. The use of this technique may be of significant value in preventing or reducing the incidence of acquired subglottic stenosis.
  Gaynor EB. Danoff SJ. The role of gentle ventilation in prevention of subglottic stenosis in the newborn. Otolaryngology - Head & Neck Surgery. 109(4):701-6, 1993 Oct.
  Nasal continuous positive airway pressure (CPAP) is being used more frequently in neonatal intensive care units to avoid endotracheal intubation and its attendant complications. Nasal deformities secondary to the nares-occluding prongs employed to deliver the CPAP in former preterm infants have been recognized, and prevention and surgical treatment of these deformities are discussed. An awareness of the potential for these deformities is important to all pediatric otolaryngologists as nasal CPAP is gaining increasing favor as a primary treatment for respiratory disease of the newborn.
  Ref : Loftus BC. Ahn J. Haddad J Jr.Neonatal nasal deformities secondary to nasal continuous positive airway pressure. Laryngoscope. 104(8 Pt 1):1019-22, 1994 Aug.
REFERENCE
  1. Bert F.. Lambert-Zechovsky N. Sinusitis in mechanically ventilated patients and its role in the pathogenesis of nosocomial pneumonia. [Review] [84 refs]. European Journal of Clinical Microbiology & Infectious Diseases. 15(7):533-44, 1996 Jul.
  2. Lipp M. Daublander M. Thierbach A. Reuss U. Movement of the temporomandibular joint during tracheal intubation. [German]. Anaesthesist. 45(10):907-22, 1996 Oct.
  3. Cooper RM. Conversion of a nasal to an orotracheal intubation using an endotracheal tube exchanger [letter]. Anesthesiology. 87(3):717-8, 1997 Sep.
  4. DDonn SM. Blane CE Endotracheal tube movement in the preterm neonate: oral versus nasal intubation. Annals of Otology, Rhinology & Laryngology. 94(1 Pt 1):18-20, 1985
  5. Kulozik U. Georgi R. Krier C. Intubation with the Combitube-TM in massive hemorrhage from the locus Kieselbachii. [German]. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie. 31(3):191-3, 1996 Apr
  6. O'Hanlon J. Harper KW. Epistaxis and nasotracheal intubation--prevention with vasoconstrictor.
  7. Irish Journal of Medical Science. 163(2):58-60, 1994 Feb.
  8. Rouby JJ. Laurent P. Gosnach M. Cambau E. Lamas G. Zouaoui A. Leguillou JL. Bodin L. Khac TD. Marsault C. et al. Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. American Journal of Respiratory & Critical Care Medicine. 150(3):776-83, 1994 Sep.
  9. Loftus BC. Ahn J. Haddad J Jr.Neonatal nasal deformities secondary to nasal continuous positive airway pressure. Laryngoscope. 104(8 Pt 1):1019-22, 1994 Aug
   

Dr Kadiyali M Srivatsa.
Copyright © 1995 [Kingsmead]. All rights reserved.
Revised: January 07, 2000.