Oxygenation: Respiratory : Endotracheal Tube Care

Repositioning the Endotracheal Tube

Purpose

  1. To prevent continuous pressure on one area of the lips.
  2. To replace the tube if the chest X-ray shows improper placement.

Assessment

Equipment

Procedure

  1. Provide privacy and explain the procedure to the client, even if the client does not appear to be alert.
    Rationale: Explanation protects client's rights and encourages client's participation in care.
  2. Wash your hands.
    Rationale: Handwashing reduces transfer of microorganisms.
  3. Assemble all equipment at the client's bedside. Using the sterile technique, set up the suction equipment. Have a handheld resuscitation bag with a mask available in case the tube is dislodged from the client's airway.
  4. If using a commercially prepared holder, open the package and refer to the manufacturer's instructions.
  5. Tear two long strips of tape, one 14" and one 24". Lay the 24" tape down with the sticky side up. Place the 14" strip of tape sticky side down on the center of the 24" tape. Split the 24" tape 5" at each end.
    Rationale: ProtectTape is prepared to secure ET tube.
  6. Don gloves and personal protective equipment.
    Rationale: Gloves and equipment protect you from secretions.
  7. Procure assistance from a respiratory therapist or another nurse to prevent accidental extubation during the procedure if the client coughs.
    Rationale: Assistance promotes client safety by allowing one person to hold ET tube in place while other performs procedure.
  8. Suction the client's trachea through the ET tube to remove any secretions, which can cause the client to cough during the procedure. Suction the client's pharynx to remove any secretions that may have accumulated above the tube cuff (Fig. 1).
    Rationale: Coughing increases risk of trauma and tube dislodgment. Suction removes accumulated secretions above cuff and helps to prevent aspiration of secretions during cuff deflation.

    9. Fig. 1A: Insert catheter into the ET tube.

    Fig. 1B: Apply suction by depressing the button with the thumb of
    the nondominant hand.

  9. To prevent traumatic manipulation of the tube, instruct the assisting nurse to hold it as you carefully untape the tube or unfasten the commercial tube holder. When freeing the tube, locate a landmark, such as a number on the tube, or measure the distance from the client's mouth to the top of the tube. If you inadvertently cut the pilot balloon on the cuff, immediately call the person responsible for intubation in your facility, who will remove the damaged ET tube and replace it with one that is intact. Do not remove the tube; a tube with an air leak is better than no airway.
    Rationale: A landmark or reference point will ensure tube is not inserted or withdrawn during procedure.
  10. Deflate the cuff by attaching a 10-mL syringe to the pilot balloon port and aspirating air until you meet resistance and the pilot balloon deflates.
    Rationale: Deflate cuff before moving tube because cuff forms a seal within trachea and movement of an inflated cuff can damage tracheal wall and vocal cords.
  11. Reposition the tube, as necessary, noting new landmarks or measuring the length.
  12. Immediately, instruct the client to inhale while you slowly inflate the cuff using a 10-mL syringe attached to the pilot balloon port or a cuff balloon manometer. As you inflate, use your stethoscope to auscultate the client's neck to determine the presence of an air leak.
    Rationale: The cuff is being inflated to the minimal pressure to occlude the trachea around the tracheal tube. The lack of an air leakage indicates over inflation of the cuff.
  13. When air leakage ceases, stop cuff inflation and, while still auscultating the client's neck, aspirate a small amount of air until you detect a slight leak. Aspiration should create a minimal air leak, which indicates that the cuff is inflated at the lowest pressure possible to create an adequate seal.
  14. If the client is being mechanically ventilated, aspirate to create a minimal air leak during the inspiratory phase of respiration because the positive pressure of the ventilator during inspiration will create a larger leak around the cuff.
  15. Note the number of cubic centimeters of air required to achieve a minimal air leak.
  16. Measure cuff pressure and compare the reading with previous pressure readings.
    Rationale: Comparison of readings prevents overinflation.
  17. Secure the tube in place.
  18. If using a commercial tube holder, fasten it according to the manufacturer's instructions.
  19. If using tape, apply benzoin above and below the lip. Place the nonsticky section of tape under the client's neck. Grasp one end of the sticky tape, press half of the split tape end across the upper lip, and wrap the other half around the tube. Repeat with the other end.
  20. Assess the client's breath sounds. Make sure that the client is comfortable and the airway patent.
    Rationale: Assessment promotes client safety.
  21. Properly clean or dispose of equipment.
    Rationale: Cleansing and disposal reduces transfer of microorganisms.
  22. When the cuff is inflated, measure its pressure at least every 8 hours to avoid overinflation. (See the "Obtaining Tracheal Cuff Pressure Measurement" procedure.)
    Rationale: Overinflation of cuff can compromise blood supply to tracheal mucosa.
  23. Record the date and time of the procedure, reason for repositioning (such as malpositioning shown by chest X-ray), new tube position, total amount of air in the cuff after the procedure, complications and nursing actions taken, and the client's tolerance of the procedure.
Sample Documentation
03/12/10 1200 ET tube holder is soiled by secretions, client's trachea and pharynx suctioned for thick yellow secretions. ET tube 15 cm at the left lip, repositioned to 15 cm at the right lip. Cuff reinflated with a minimum occlusive pressure of 22 cm H2O. Client tolerated the procedure without difficulty. Natalie Conway, RN

Lifespan Considerations

Children Older Adults