Repositioning Of Endotracheal Tube Research Articles

Nursing interventions to prevent pressure injury among open heart surgery patients: A systematic review.

Nurses are vital in identifying and preventive pressure injuries (PIs) in hospitalized patients undergoing open heart surgery. Interventions to prevent PIs are crucial for every critical patient, and it's essential to recognize that preventing PIs involves a complex intervention. To examine the nursing interventions for the prevention of PI in patients with open heart surgery. A systematic review study. Web of Science, Science Direct, PubMed, Scopus, MEDLINE Ultimate, CINAHL Ultimate, ULAKBIM, Cochrane Library, Google Scholar and university library databases were scanned. The initial search performed in the databases was updated on 4 February 2023, and on 7 April 2024, for potential publications included in that period. Data between February 2013 and April 2024 were scanned. The databases were searched with the keywords 'pressure injury', 'nursing interventions' and 'open heart surgery'. The systematic compilation process was carried out in accordance with the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide. Seventeen studies were examined using nursing interventions that applied to the selected study population. Care packages included an inflatable head pad, a pressure sensor mattress cover, multi-layer silicone foam, pressure-reducing coatings, endotracheal tube (ETT) repositioning and cuff pressure regulation. Interventions to reduce PI in open heart surgery patients are applied in the preadmission, perioperative and postoperative periods. It was concluded that care packages, inflatable head pads, pressure sensor bedspreads, multi-layered silicone foam, pressure-reducing covers, ETT repositioning and cuff pressure regulation were effective in all nursing interventions. The strength of the available evidence was rated from strong to weak. These findings reveal an efficient combination of multi-component nursing interventions for preventing PIs in planning patient care in the intensive care. The interventions that are used throughout the patient's entire care process are crucial for the prevention of PIs.

A study of the utility and safety of bronchoscopy in mechanically ventilated COVID19 ARDS: Transgressing the conventional guidelines

Background: Bronchoscopy has been done sparingly in COVID19 patients due to the risk of aerosol generation. We describe a study on targeted bronchoscopy in mechanically ventilated (MV) COVID-19 patients outlining the procedural, clinical, utilitarian and safety aspects. Methods: Bedside bronchoscopy was performed in suspected or confirmed COVID-19 cases on MV for specific indications. Demographic, clinical, bronchoscopic and laboratory findings were analysed. Results: 98 procedures were performed on 61 patients, mean age 62.1 years, 51 (83.6%) males. 42 patients (69%) had at least 1 co-morbidity. Major indications were new radiographic infiltrates with clinical deterioration, increased endotracheal tube (ETT) secretions and haemorrhagic secretions/hemoptysis. Common findings were copious secretions in 87 (88.8%), purulent in 61%, mucoid in 18%, haemorrhagic in 7% and frothy in 14% cases. On the management front, antibiotics were changed in 31 (31.6%) cases based on bronchoscopic findings. Other significant changes included reduction/stopping steroids and anticoagulation and ETT repositioning. The incidence of bacterial superinfection was high (54% culture positivity), a significant number (94%) with multi-drug resistant organisms. Fungi were seen in 7 cases (7.1%). Pneumocystis jiroveci was not seen and cytology did not show any viral inclusions. Therapeutic mucus plug removal was done in 30 cases (30.6%), and hemoptysis control in 4% cases. The procedures were safe and none of the HCW developed any COVID19 disease. Conclusion: Bronchoscopy in critically ill MV COVID-19 patients contributes on both diagnostic and therapeutic fronts and impacts management decisions. With adequate precautions and standard protocols, it is safe for both HCW and patients.

Airway Manoeuvres during Anaesthetic Management of Adult Acquired Tracheo-Oesophageal Fistula

Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.

“A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children

The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An "A-OK" algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-"A-OK" patients were compared with pre-"A-OK" controls regarding the speed of malpositioned ETT repositioning. Twenty-eight post-"A-OK" cases and 23 pre-"A-OK" controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-"A-OK" controls than in post-"A-OK" cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.

Clinical study of accurate repositioning of endotracheal tube in percutaneous dilatational tracheotomy for patients undergoing mechanical ventilation

Objective To explore the feasibility and safety of ultrasound-guided endotracheal tube (ETT) withdrawal and repositioning during percutaneous dilatational tracheostomy (PDT) in patients with mechanical ventilation. Methods One hundred and twenty patients undergoing general anesthesia were selected and the incisor-glottic distance was measured under direct vision by the laryngoscope. Subsequently, eighty patients scheduled to undergo PDT were selected and divided into conventional incision group (group T) and ultrasound-guided group (group U) by Excel random number generation method, with 40 cases in each group. The puncture site was identified though anatomical landmarks in group T and real-time ultrasound guidance in group U respectively. Before incision, ETT was withdrawn to 20 cm (the incisors correspond to the ETT scale) in group T whereas the cuff of ETT was retracted to the level of the cricoid cartilage under ultrasound guidance in group U. The one-time success rate of trachea puncture and guide wire insertion were recorded and compared. The occurrence rate of ETT and cuff puncture, the rate of premature loss of airway control, operation time, the incidence of SpO2 less than 90% in the process of PDT and the success rate of percutaneous tracheotomy tube (PTT) insertion were also recorded and compared. Results The average incisor-glottic distance of one hundred and twenty patients was (16.7±1.1) cm [(17.1±1.1) cm for males and (16.2±1.0) cm for females], with a maximum of 20.0 cm and a minimum of 14.5 cm. The one-time success rate of trachea puncture in group U was significantly higher than that of group T(P 0.05). Conclusions Ultrasound-guided ETT withdrawal and repositioning is feasible and safe. This method can avoid the interference of ETT in PDT, increase the success rate of tracheal puncture, shorten the operation time, and improve the oxygenation during operation. Key words: Ultrasound guidance; Percutaneous dilatational tracheostomy; Endotracheal tube

Repositioning of endotracheal tube and risk of ventilator-associated pneumonia among adult patients: A matched case-control study.

INTRODUCTION:Ventilator-associated pneumonia (VAP) is one of the most serious hospital-acquired infections to occur among mechanically ventilated patients. Many risk factors for VAP have been identified in the literature; however, there is a lack of studies examining the association between endotracheal tube (ETT) repositioning and an increase in the risk of VAP. The aim of the present study, therefore, was to investigate the effect of ETT repositioning and the risk of developing VAP.METHODS:Matched case-control studies were conducted among mechanically ventilated patients admitted to the intensive care unit (ICU) at King Abdulaziz Medical City from 2016 to 2018. Patients who had a documented VAP diagnosis were identified and matched to four controls (within a 10-year age band). The history of ETT repositioning (defined as changes in the positioned ETTs from the first reading at the time of ETT insertion) was explored in the medical files of the sample, as were other demographic and comorbidity risk factors. Logistic regression analysis was used to test the association between ETT repositioning and VAP.RESULTS:A total of 24 cases were identified with documented VAP diagnosis during the study. Those cases were matched to 81 controls. The mean age was 55 (standard deviation 21) for both cases and controls. VAP patients had a greater history of ETT repositioning (46%) compared to controls (29%). Patients who had a history of ETT repositioning were twice as likely to develop VAP as patients who had no history of ETT repositioning (P = 0.13). After adjustment of a potential confounder, the results showed evidence of an increased risk of VAP after ETT repositioning (odds ratio 3.1, 95% confidence interval 1.0–9.6).CONCLUSION:Reposition of ETT considers as a risk factor for VAP in ICU patients, and appropriate measures should be applied to reduce movements of the ETT tube.

Association of endotracheal tube repositioning and acute laryngeal lesions during mechanical ventilation in children.

The objective of this study is to determine the incidence of post-extubation acute laryngeal lesions in a pediatric intensive care unit (PICU) and potential risk factors. Children, aged 28days to 5years, admitted to the PICU who required endotracheal intubation for at least 24h were enrolled.Exclusion criteria were a previous intubation, history of laryngeal disease, current or past tracheostomy, the presence of craniofacial malformations and patients considered on palliative care. All patients underwent flexible fiber-optic laryngoscopy (FFL) not later than 8h after extubation. A blinded researcher identified and classified laryngeal lesions based on recorded media. 231 children were enrolled between November 2005 and December 2015. At FFL examination, 102 children (44.15%) presented moderate to severe laryngeal lesions. On a multivariable analysis, we found that for each additional day with repositioning of the endotracheal tube, there was an increase of 7.3% (RR 95% CI 1.012-1.137; P=0.018) on the baseline risk of developing moderate to severe acute laryngeal lesions. Furthermore, for each additional dose of sedation per day of intubation, there was also an increase of 3.5% on the same baseline risk (RR 95% CI 1.001-1.070; P=0.041). The amount of tube repositioning episodes and the need for extra doses of sedation (as a proxy for possible agitation) were found to be associated with acute laryngeal lesions. Adequate sedation and minimized tube repositioning should be pursued to possibly prevent the development of post-extubation airway compromise.

Post-operative pneumothorax with subcutaneous emphysema in a pre-eclamptic patient.

Sir, A 30-year-old female patient presented with severe pre-eclampsia for emergency caesarean section. On the operating table, she had a blood pressure (BP) of 176/98 mm Hg, pulse rate 102/min, oxygen saturation (SpO2) 99% and air entry was equal bilaterally. Rapid sequence induction and intubation were performed; gentle laryngoscopy was performed and cuffed endotracheal tube (ETT), 7.5 internal diameter was inserted aided by a stylet. The depth of anaesthesia was maintained with O2, nitrous oxide, isoflurane and muscle relaxant vecuronium (total dose of 6 mg) was used. The monitors used were electrocardiograph, pulse oximeter, non-invasive BP, and end-tidal carbon dioxide (CO2) monitor. The patient was ventilated on closed circuit with mechanical ventilation (volume control mode with respiratory rate [RR] 12/min, tidal volume of 450 ml, without positive end-expiratory pressure (PEEP), with mean airway pressure of 14 cm H2O). Intra-operative period was uneventful. The surgery was completed in 1 h. Postoperatively, the neuromuscular blockade was reversed with neostigmine 2.5 mg intravenous (iv), glycopyrrolate 0.5 mg iv. Due to inadequate reversal of neuromuscular blockade as suspected by poor respiratory efforts, the reversal drugs were supplemented. Arterial blood gas report showed normal partial pressure of oxygen and potential of hydrogen. However, CO2 retention was present, so we continued to manually assist her ventilation. After 10 min, her respiratory efforts were adequate, but her protective airway reflexes were blunted and she was tolerating the ETT well. Therefore, we decided not to extubate the trachea. While shifting the patient to recovery room on T piece, she had a violent coughing and retching episode after which she became restless and developed bradycardia with SpO2 decreasing to 82%. We then noticed palpable crepitus all over the chest, face and doubtful air entry on chest auscultation. As we suspected displacement of ETT, we extubated the trachea. She was unable to maintain adequate respiratory efforts. Hence, we paralysed her and reintubated her trachea. Thereafter, her vital signs stabilised. Air entry on the left side was decreased. She was shifted to the Intensive Care Unit (ICU) for mechanical ventilation. A chest X-ray was done in the ICU, which showed left-sided pneumothorax with subcutaneous emphysema. An intercostal chest drain was inserted and patient. The patient was maintained ventilatory support without delay (volume control mode with RR 14/min, TV 450 ml, PEEP of 0 cm H2O, inspiratory to expiratory ratio (I: E ratio) of 1:2 and peak airway pressures limited to 24 cm H2O). We could not find any obvious airway rent as assessed by fibreoptic bronchoscopy. The patient's relative did not give consent for computed tomography of thorax. After 24 h of stay in the ICU, the patient's vital signs got stabilised with normal respiratory parameters. The patient's trachea was extubated. After 24 h of cessation of air column movement, the intercostal chest drain was removed. Pneumothorax with subcutaneous emphysema in the immediate postoperative period can be spontaneous or iatrogenic. Spontaneous causes include rupture of undiagnosed bullae, spontaneous post-violent cough airway tear, alveolar rupture and post-emetic rupture of the oesophagus.[1,2,3] Iatrogenic causes include trauma to the pharynx, trachea during traumatic intubation, over inflation of ETT cuff, repeated intubation attempts, re-positioning of ETT without deflating the cuff, stylet protruding beyond ETT tip, patient movement or coughing during intubation/extubation and patient head and neck movement after intubation.[4] In our patient, adequate precautions were taken to prevent these iatrogenic causes. Decrease in SpO2 and bradycardia did not occur in the intra-operative period during which positive pressure ventilation was provided, so the aetiology being rupture of undiagnosed bullae due to positive pressure ventilation is unlikely. There are patient and surgical factors such as congenital tracheal anomalies, chronic use of steroids, chronic obstructive pulmonary disease, thoracic and laparoscopic surgeries.[4] None of these factors are involved in our case. Even though, we could not find any obvious airway rent while doing fibreoptic bronchoscopy, a possibility of airway injury cannot be completely ruled out. There is a high probability that either the violent coughing or retching episode in the post-operative period or ETT displacement due to violent head and neck movement during transfer to the recovery room could have led to an airway or oesophageal rent. We would like to create an awareness that airway trauma can lead to pneumothorax with subcutaneous emphysema in a pregnant patient due to fragile oedematous airway mucosa. We, therefore, reemphasise the importance of gentle laryngoscopy and intubation, maintenance of cuff pressure, administration of anti-emetics, smooth reversal, extubation and care of ETT while shifting the patient. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

G119(P) Patientsafety incident reporting data trends of a regional neonatal transfer service

Introduction Neonatal transfers take place in a high-risk environment and patient safety must be a key priority. Methods Risk reporting for this regional transfer service has evolved over the last five years. The patient safety incident form has been adapted over the last 3 years, providing a clear structure of what is to be reported, ensuring the significance of the adverse event is considered and the response to the incident recorded. This study reviewed the patient safety incident forms completed over the last three years. Results Form completion significantly improved from 61% in 2011 to 96% in 2013. Comparing trends between 2012 and 2013: significant improvements were seen in delayed dispatch to time critical transfers, time delays during stabilisation, equipment problems, vascular incidents and unintended hypothermia. However, a significant increase in hypocarbia and endotracheal tube repositioning. Conclusion We report improved risk reporting and an improvement in many of the incident categories. Future work needs to focus on sustaining and improving other categories.

Ventilator associated pneumonia and endotracheal tube repositioning: An underrated risk factor

Aspiration of secretions toward lower airways potentially occurs during endotracheal tube (ETT) repositioning in mechanically ventilated patients in the intensive care unit and may be a risk factor for developing ventilator-associated pneumonia (VAP). This case-control study confirms that repositioning of the ETT is an independent risk factor for VAP.

Location of the endotracheal tube by pilot balloon-cuff counter-ballottement

Study objectives: Mastery of the airway is the primary skill of an emergency physician. A wide variety of techniques and devices have been designed to help obtain and control a patent airway during an emergency airway crisis. Presently, the criterion standard for clinical assessment of proper endotracheal tube verification in the airway is a change in the color indicator on the end-tidal carbon dioxide detector device, augmented by another method such as endotracheal tube aspiration. However, depth of insertion of the endotracheal tube or location within the trachea is usually determined clinically by symmetry of auscultated bilateral breath sounds or subsequently confirmed by postintubation chest radiograph. Earlier work in other clinical settings has demonstrated that with pilot balloon-cuff counter-ballottement (PBCCB) technique, the endotracheal tube cuff can be located externally by gentle palpation at the patient's suprasternal notch, with simultaneous counter-ballottement palpation of the endotracheal tube pilot balloon, using the pilot balloon as a cuff sensor. Palpation and compression of the inflated endotracheal tube cuff distends the pilot balloon accordingly. The purpose of this study is twofold: (1) to obtain a retrospective derivation set of patients, in which the endotracheal tube was repositioned postintubation, representing the rate of endotracheal tube malposition (ie, "usual care"); and (2) to obtain a prospective validation set after a training intervention to determine whether PBCCB provides an additional clinical tool for the emergency physician, thereby reducing the need for endotracheal tube repositioning by postintubation chest radiograph. Methods: In a random, retrospective, convenience sample, we examined 221 radiographs or radiography reports from 419 adult emergency department patients who underwent rapid sequence intubation (RSI) from July 1, 2001, through June 30, 2002. Endotracheal tube position (ie, depth of the endotracheal tube within the trachea above the carina) was quantified. The incidence of postintubation repositioning of the endotracheal tube after chest radiograph comprised the incidence of repositioning or "usual care." Next, emergency physicians received standardized group and individualized training in the application of PBCCB technique. In a subsequent random, prospective, convenience sample during 4 consecutive months, emergency physicians were asked to complete a postintubation procedure card, before the chest radiograph was reviewed, indicating whether the externally palpated endotracheal tube cuff by PBCCB technique was at (preferred), above (acceptable), or below (possibly requiring repositioning) the patient's suprasternal notch. These results were compared with those noted from the postintubation chest radiograph. Results: Of the 221 chest radiographs reviewed in the retrospective derivation set, low malposition (<2 cm above the carina) of the endotracheal tube was noted in 46 (21%), including unrecognized mainstem endobronchial intubation in 14 (30% of the low malpositioned tubes; 6% of the total intubations). In the prospective validation set, 78 postintubation procedure cards were completed for 75 RSI patients by 20 PBCCB-trained emergency physicians. Fifty-two RSI procedures (66%) included the attempted application of the PBCCB technique, whereas it was not attempted in one third (26 patients). For patients who did not undergo PBCCB assessment, 9 patients (35%) required endotracheal tube repositioning, 8 of which were repositioned according to postintubation chest radiograph alone, and 1 of which was repositioned according to asymmetrical breath sounds alone. For the 52 patients undergoing pilot balloon assessment, 16 (31%) endotracheal tubes were repositioned postintubation, 6 by PBCCB technique alone, and 10 by chest radiograph alone; in all 10 of those patients, emergency physicians noted that the endotracheal tube cuff could not be localized by PBCCB, intimating that the endotracheal tube was indeed placed too low in the trachea. Conclusion: Although additional work is warranted, these preliminary observations demonstrate that the use of the PBCCB of the endotracheal tube could add to the emergency physician's airway skills armamentarium to assist in location of the endotracheal tube location within the trachea, avoiding prolonged endobronchial intubation. If validated, the technique could apply to alternative settings in which chest radiograph is not immediately available or in which bedside clinical auscultation skills are compromised by ambient noise or patient transport (eg, emergency medical services or military field medical care).