Endotracheal tube, securing - Intensive Care & Coordination ...

St Vincent’s Hospital Intensive Care Services Page 1 of 16 

Securing an ETT: Intensive Care Clinical Practice Manual, Policy / Procedure R 4.1 

Title CP/Pol/Proc: Securing an endotracheal tube in Intensive Care. 

Subject: Securing an endotracheal tube in the Intensive 

Care Unit (ICU). 

Area: Management of endotracheal tubes. 

Classification: Clinical Practice 

Relevant to: Nursing and medical staff in ICU. 

Implementation Date: 7 July 2006 

Review Date: 7 July 2009 

Responsible for Review: ICU Campus Committee 

Approved by: ICU Medical Director: Dr Bob Wright 

Distribution: ICU 

Location: Intensive Care Clinical Practice Manual 

1.0 OUTCOME 

All patients with an endotracheal tube (ETT) shall have their tube safely and 

appropriately secured. 

2.0 POLICY 

All ETTs in ICU must be secured according to the following protocol. 

3.0 SCOPE OF POLICY 

This policy relates to the securing of ETTs in ICU patients by medical and nursing staff 

working in ICU. 

Securing an ETT Policy / Procedure R 4.1 Page 1 of 16 

ICU Clinical Practice Manual Implemented July 2006, Review July 2009.



4.0 DEFINITIONS 

An ETT is a breathing tube which is passed through a patient’s oro or naso -pharynx into 

the trachea in order to allow a patient to be ventilated. 

Intubation refers to the passage of the ETT into the trachea. 

Extubation is the removal of the ETT from the patient’s trachea. 

5.0 INDICATIONS 

All patients who have an ETT must have it safely and appropriately secured. 

The standard way of securing ETTs at St Vincent’s ICU is to use trachy tape as described 

in Section 7.1 and 7.2. 

The technique using brown leukoplast tape is indicated for patients who should avoid 

having tape tied around the back of their neck. This includes patients who have had 

neurosurgical procedures and major head and neck surgery. In these situations the tape 

may cause venous congestion of the brain or impair the perfusion of free grafts by 

pressure on the arterial supply or venous drainage. 

The technique using the Oral Endotracheal Tube Attachment Device (E-TAD) is 

indicated for adult patients requiring longer term intubation (eg greater than 3 days). It is 

NOT appropriate for patients who: 

• Don’t have teeth or are unable to wear upper dentures 

• have full lips, facial swelling or protruding teeth 

• have moustaches or full beards. 

This technique is described in Section 7.5 and 7.6. 

6.0 PRINCIPLES 

Appropriately and safely securing an ETT lessens the risk of accidental or self 

extubation. It also prevents migration of the tube to an unsafe and potentially harmful 

position either upwards into the larynx or downwards into the right main bronchus. 

Securing an ETT will be carried out utilizing the following practice principles: 

• Aseptic technique 

• Patient comfort and safety 

• Anatomy and physiology 

• Body substance isolation 





6.1 Principles of Risk Management. 

The following risk management principles shall also be applied in reference to 

the securing of ETTs: 

• Once a tube is in place it must be secured so that it cannot fall out and 

so that it cannot migrate upwards or downwards. 

• Re-tying of the ETT should be done as infrequently as possible and 

never as a routine. 

• Securing an ETT is a two person procedure. At no time must a tube be 

left unsecured. The ETT must be secured by hand by a dedicated 

nurse or doctor when the tube is being tied or re-tied. 

• If it is necessary to re-secure an ETT, this procedure ideally should be 

carried out when staff are fresh and alert (eg not at the end of a tiring 

shift) and a medical officer is available should a tube become 

accidentally dislodged and emergency re-intubation becomes 

necessary. 

• Once a tube is placed, clinical examination should confirm that there 

is equal air entry. 

• The chest Xray should be viewed to confirm the tip of the ETT is just 

above a line half way through the aortic knob ( or 2 cms above the 

carina). 

• Once the correct position has been established the tube should be cut 

at 2.5 cm from the lips to prevent potentially fatal migration. 

• One of the following written protocols must be used to secure the 

ETT. 





7.0 APPLICATION OF PRINCIPLES 

PLEASE NOTE THAT THE ETT MUST BE SECURED BY HAND BY A 

DEDICATED NURSE OR DOCTOR WHEN THE TUBE IS BEING TIED OR RE- 

TIED. FOR THE SAKE OF CLARITY ALL THE FOLOWING 

ILLUSTRATIONS DO NOT SHOW THE ASSISTANT’S HAND. 

7.1 EQUIPMENT REQUIRED FOR TRACHY TAPE METHOD 

Trachy tape (long enough to pass around the neck and tie several knots). 

Scissors 

Two foam pads. 

7.2 PROCEDURE FOR TRACHY TAPE METHOD 

. Pass the tape around the neck and then tie it firmly between the nose and tube 

with a Surgeon’s knot (i.e. an initial double throw of the tape so that the correct 

tension can be maintained). 





ii. Follow this with a single locking throw. (Don’t tie this knot between the tube 

and chin as it predisposes to the tube slipping over receding chins.) 

iii. Tie a very firm reef knot (left over right then right over left) around the tube 

so that the tube cannot slip up or down. 





iv. Tie another firm reef knot back the other way (belt and braces). 





v. Cut the ends at 2.5 cms. Never cut the ends short as it will unravel. 

vi. Place foam pads under the tape at the edges of the mouth to prevent pressure 

sores. 

(A video demonstration of this technique by Dr Bob Wright is available on the 

desktop computers. See folder called ETT Security.) 





7.3 EQUIPMENT REQUIRED AND PREPARATION FOR 

LEUKOPLAST TECHNIQUE. 

Prepare tape according to the following picture (two uneven trouser legs, one 

even trouser legs, one long double sided piece). The second picture demonstrates 

the reverse side of the longest double sided strip that goes behind the patient’s 

neck. 





7.4 PROCEDURE FOR LEUKOPLAST TECHNIQUE. 

i. Use one piece of the uneven trouser leg to secure the longer piece of tape to the 

patient’s upper lip and secure the shorter leg around the ETT as demonstrated 

below. 





ii. Repeat the procedure with the other uneven trouser leg tape, except apply the 

longest section to the lowest lip and wrap the shorter piece around the ETT. 





iii. Secure the even trouser leg tape to the other side of the face and secure the 

tape along the upper and lower lips as demonstrated below. 





iv. Pass the double sided tape around the patient’s neck. (You may need to 

temporarily stick an unused tongue depressor or syringe to one end of the tape in 

order to be able to pass it under the neck.) 

v. Secure the adhesive sections of this leukoplast to the leukoplast that is already 

on the patient’s cheeks as demonstrated below. 





7.5 EQUIPMENT REQUIRED AND PREPARATION FOR E –TAD. 

One E-TAD. 

Shave area as appropriate. 

Ensure the patient’s skin in the area of use is clean, dry and free from oily residue. 

7.6 PROCEDURE FOR E – TAD. 

i. Remove the release liner from the skin barrier. 

ii. Centre the device on the patient’s upper lip with the clamping mechanism 

approximately 1.25 cms below the upper lip. Press the adhesive barrier on the 

patient’s skin and hold in place until it adheres well. This will take about 30 

seconds. 

iii. Apply the neck band and secure through the appropriate loops and attach the 

Velcro. 





iv. To secure the tube, squeeze the tabs on the outer edges and move it along the 

track to a location above the tube. The tube should normally be located on the side 

of the mouth closest to the ventilator. 

v. Remove the release liner from the strap, expose the adhesive and wrap it 

around the tube. Pull the remaining portion of the strap through the clamp. 





vi. Secure the strap by snapping the clamp shut (an audible click will be heard). 

(Above E - TAD instructions taken from E – TAD product pamphlet, Hollister, 

Ontario, 2000) 





8.0 DOCUMENTATION 

Tying or re-tying of ETTs is recorded in the medical progress notes. 

The length of the ETT at the lips is recorded each shift on the ICU Flowchart. 

9.0 RESPONSIBILITY 

Medical and nursing clinical staff in ICU are responsible for ensuring that ETTs are 

safely and appropriately secured. 

10.0 ACKNOWLEDGEMENTS 

Thanks to Ms Debra Moss (Nurse Educator ICU) for demonstrating the different 

techniques and advising upon instructions. 

11.0 CROSS REFERENCES 

ICU Clinical Practice Manual, Intubation, R.4. 

ICU Clinical Practice Manual, Extubation, E.6. 

12.0 REFERENCES 

Hollister Incorporated, E TAD Instructions (product insert), Illinois, 2000. 

Dr Bob Wright, Personal Correspondence, April 2005. 

13.0 ENDORSED BY 

Dr Bob Wright, Medical Director ICU. 

Mr. J Breeding, CNC ICU.

Endotracheal tube, securing - Intensive Care & Coordination ...

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