Methods for securing endotracheal tubes in newborn infants

Review question

Over the years, there have been multiple different ways an endotracheal tube has been secured in the ventilated newborn. We reviewed the evidence for the most effective method to secure an endotracheal tube in infants requiring mechanical ventilation. We found five randomised controlled trials which compared different methods of securing an endotracheal tube and studied their effects on outcomes such as accidental extubation.

Background

As neonatal care and the survival rates of premature infants continues to improve, there will be an ongoing need for newborns to be intubated and ventilated. These are often the sickest babies in the nursery, so optimising practice in this area could impact outcomes. The aim of effectively securing an endotracheal tube is to provide continuous optimal ventilation whilst minimising the risk of developing complications from an unstable tube.

Search date

The evidence was current to June 2013.

Study characteristics

The five studies included in this review enrolled patients from a neonatal intensive care nursery who were intubated and ventilated. Trial durations ranged from the time required to enrol the small recruitment targets up to 10 months. Numbers of participants in the studies ranged from 30 to 203 ventilated infants.

Key results

Accidental extubation was the outcome measured in all five studies and was the outcome of interest in this review. Other secondary outcomes included skin trauma, tube slippage and rates of preventive re-taping. All five studies compared methods of securing the endotracheal tube that were too dissimilar for the data to be collated or included in a meta-analysis.

Quality of the evidence

The overall quality of the evidence was low. Limitations in design and implementation were evident to different degrees in all five studies. None of the studies indicated whether allocation was concealed. Due to the nature of the intervention the studies were unable to be blinded, however none of the studies indicated whether data were collected in a blinded fashion therefore conferring risks of bias. One study had a large group of neonates that were excluded from the analysis and publication bias. Conclusive results from well designed and conducted trials could help to optimise current practice.

Authors' conclusions: 

This review highlighted the need for further well designed and completed studies to be conducted for this common neonatal procedure. Evidence is lacking to determine the most effective and safe method to stabilise the endotracheal tube in the ventilated neonate.

Read the full abstract...
Background: 

Securing the endotracheal tube is a common procedure in the neonatal intensive care unit. Adequate fixation of the tube is essential to ensure effective ventilation of the infant whilst minimising potential complications secondary to the intervention. Methods used to secure the endotracheal tube often vary between units and sometimes even between healthcare providers in the same nursery.

Objectives: 

To compare the different methods of securing the endotracheal tube in the ventilated neonate and their effects on the risk of accidental extubation and other potential complications that can result from an unstable endotracheal tube.

Search strategy: 

A literature search of MEDLINE (from 1966 to June 2013), CINAHL (from 1982 to June 2013) and CENTRAL in The Cochrane Library was conducted to identify relevant trials to be analysed.

Selection criteria: 

All randomised and quasi-randomised controlled trials of infants who were intubated for mechanical ventilation in a neonatal intensive care nursery where methods of stabilising the endotracheal tube were being compared.

Data collection and analysis: 

Data were collected from individual studies to determine the methods being compared, the methodology of the trial, and whether there were areas of bias that could significantly affect the results of the studies. In particular, studies were assessed for blinding of randomisation and allocation, blinding of the intervention, completeness of follow up, blinding of outcome assessments and selective reporting.

Main results: 

Five randomised controlled trials were identified and included for review. Accidental extubation was the most common outcome measured (five studies). None of the studies reported on the need for re-intubation or the rate of tube malposition, however one study did report on endotracheal tube slippage. A variety of other adverse effects were reported including mortality, incidence of perioral skin trauma and tube re-taping. All five studies were of poor methodological quality, small size, contained significant risks of bias and compared methods of securing the endotracheal tube that were too dissimilar for the data to be collated or included in a meta-analysis. We have not reported these further.

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