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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 74-85

Factors affecting fixation of endotracheal tube among children in intensive care units


1 Department of Pediatric Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
2 Department of Pediatric Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission12-Aug-2020
Date of Decision03-Sep-2020
Date of Acceptance27-Aug-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Shaymaa M.A Gebril
Department of Pediatric Nursing, Faculty of Nursing, Cairo University, Cairo, 11562
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_25_20

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  Abstract 


Background Correct positioning and proper fixation of the endotracheal tube (ETT) among children can be challenging in pediatric intensive care units (PICUs), and improper fixation may be associated with higher rates of complications.
Aim The study aimed to explore factors affecting fixation of ETT among children in ICU.
Patients and methods A descriptive exploratory design was utilized. Setting: the study was conducted at PICUs in two Pediatric University Hospitals affiliated to Cairo University hospitals. Sample: a convenient sample of 101 intubated children in ICUs was enrolled in the study. Tools: the required data were collected by using personal data questionnaire for child, assessment sheet of factors affecting ETT fixation in PICU, and observational checklist of securing an ETT.
Results The current study results revealed that more than half of the children had improperly fixed ETT, and more than two-thirds of them were less than 1 year old and two-thirds of them were males. Years of experience of the assigned nurse in PICU less than 2 years, inappropriate child position in bed, ETT fixation with adhesive tape without tube holder, traction of ETT, inappropriate mechanical ventilator (MV) circuit position, inappropriate handling of child during performance of procedures and care, nurse shift (morning shift), incorrect ETT retaping by the assigned nurse, absence of documentation of ETT card, and increase length of stay on MV and in PICU were statistically significant factors associated with improper ETT fixation.
Conclusion Absence of salivary secretions in child mouth was the most frequent finding in children with properly fixed ETT, followed by appropriate MV circuit position, appropriate child position in bed, experience of the assigned nurse of more than 2 years in PICU, passive movement of child, no traction of ETT, and appropriate handling of child. On the contrary, ETT fixation with adhesive tape without tube holder was the most frequent finding in children with improperly fixed ETT followed by no documentation of ETT card, uncuffed ETT, morning shift, stay in PICU more than 2 weeks, MV days more than 1 week, and nurse’s experience in PICU of less than 2 years.
Recommendations Standard method of fixation of ETT should be used in all children by adhesive tape with tube holder, and also ETT position should be checked and documented with every nursing shift.

Keywords: children, endotracheal tube fixation, factors, pediatric intensive care units


How to cite this article:
Gebril SM, Darwish MM, Mahmoud NF, Aziz MM. Factors affecting fixation of endotracheal tube among children in intensive care units. Egypt Nurs J 2020;17:74-85

How to cite this URL:
Gebril SM, Darwish MM, Mahmoud NF, Aziz MM. Factors affecting fixation of endotracheal tube among children in intensive care units. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:74-85. Available from: http://www.enj.eg.net/text.asp?2020/17/1/74/300782




  Introduction Top


The percentage of pediatric patients requiring mechanical ventilation (MV), endotracheal intubation, and hospitalized in ICU varies between 30 and 64%. MV is a life-support therapy aimed at maintaining adequate alveolar ventilation and effective gas exchange in critically ill patients (Christopher et al., 2019). In Egypt, the data from statistical department in Cairo University Specialized Pediatric Hospital (CUSPH) indicated that the admission rate of children admitted to Pediatric Intensive Care Units (PICUs) from 2014 to 2015 was 1200 children, but there are no statistics for the rate of intubated children.

Once a child is intubated, maintenance of the endotracheal tube (ETT) fixation is essential. When the ETT is not fixed effectively, even basic nursing management can cause tube slippage, which is a major factor in causing airway trauma (Ahmed and Boyer, 2020). Inadequate fixation of the ETT can result in rapid deterioration and difficult recovery in sick children with respiratory failure, and also frequent reintubations have been correlated with subglottic stenosis, airway trauma, and pulmonary air leak, which can be hazardous and life-threatening (Robert et al., 2015).

Besides that, unsuccessfully fixed ETT has the potential of worsening outcome by exposing patients to complications of premature removal of ventilator support and has an effect on mortality, respiratory failure, duration of MV, and length of stay in PICU and hospital stay (Da Silva and Fonseca, 2017). Moreover, Roddy et al. (2015) studied the effect of accidental extubation in children and its effect on hospital cost and length of stay and reported that pediatric patients with unplanned extubation have an associated increase in hospital costs and length of stay as compared with age-matched and diagnosis-matched controls.

Harris et al. (2016) emphasized that evaluation of improper fixation of ETT and accidental extubation includes physical and clinical signs, such as tube displacement, the presence of vocalization, sudden unexplainable air escape, gastric distension, cyanosis or a reduction in peripheral oxygen saturation, and the absence of respiratory movements and/or air entry to the lungs. Furthermore, Tripathi et al. (2015) reported that risk factors associated with inadequate fixation included age younger than 2 years, male sex, agitation, high salivary secretion, duration of intubation, cause of admission, use of physical restraints, nurse/child ratio, and procedures of care such as changing position, suctioning, bathing, and radiograph.

Recently, Nina et al. (2020) conducted a study exploring factors that affect ETT fixation to achieve sustainability in reducing unplanned extubations in a pediatric cardiac ICU and reported that total number of children supported with MV was 2067, and 45 of them had 49 episodes of improper ETT fixation. They added that the average improper ETT fixation rate per 100 ventilator days was 0.4. Furthermore, they emphasized that patients who had improper ETT fixation and unplanned extubation were younger, weighed less, and had a longer length of MV than those who had proper ETT fixation. Moreover, they concluded that contributing factors associated with improper ETT fixation and unplanned extubation were poor ETT tape integrity, inadequate tube securement, and/or inadequate sedation.

Da Silva and Fonseca (2017) emphasized that understanding all factors affecting fixation of ETT is crucial for identifying children at risk of improper ETT fixation, for developing interventions to reduce rate of mortality and length of stay in PICU, and prevent complications of emergency intubation. So, the findings from the current study will add evidence-based research to the body of knowledge in pediatric nursing and will act as a base for developing nursing care guidelines in caring for intubated children in PICUs, which will assist in pediatric nursing practice. Therefore, the aim of the present study was to explore factors affecting fixation of ETT among children in ICU.


  Patients and methods Top


Aim

The aim of this study was to explore the factors affecting fixation of ETT among children in ICU.

Research question

What are the factors affecting fixation of ETT among children in ICU?

Research design

A descriptive exploratory research design was used to achieve the aim of the current study.

Setting

The proposed study was conducted at two pediatric university hospitals affiliated to Cairo University hospitals:
  1. Pediatric University Hospital, where the ICU is situated on the seventh floor. This ICU contains 27 MVs for all age groups and 18 beds in two parts: the first part contains 13 beds for different diagnoses (three beds for isolated cases, three resuscitation beds for young infants, and another seven beds for older children), and the second part contains five beds, also for different diagnoses (three resuscitation beds for young infants and two beds for older children).
  2. Specialized Pediatric University Hospital, where there are three ICUs: the first one is on the fourth floor and consists of 14 beds; the second one is on the six floor, which consists of two parts, where the first part contains seven beds for older children and the second part contains four resuscitation beds for young infants and another three beds for older children; and the last one was the emergency unit in the first floor, which consists of 17 beds.


Sample

A convenient sample of 101 intubated children in PICUs was recruited during the duration of 6 months from January 2017 to June 2017. All children who were connected to MV and aged from 1 month to 18 years were included in the study. Children connected with tracheostomy for MV were excluded.

Data collection tools

The research investigator used Pediatric Advanced Life Support guidelines (ETT depth=age in years/2+12) developed by Chameides et al. (2011) to calculate the estimated depth of ETT insertion for each patient to determine if ETT was properly fixed or not and then the other required data were collected through the following tools which had been developed by the research investigator after extensive review of related literature:
  1. Personal Data Questionnaire of child:

    It included questions about age, sex, and medical diagnosis.
  2. Assessment sheet of factors affecting ETT fixation in PICU:

    It consisted of four parts:

    Part I:

    Factors related to the child: it involved questions about weight of child, PICU days, MV days, use of sedation, use of restraining, movement, presence of facial trauma, conscious level, positioning of the child in the bed, and presence of vomiting.

    Part II:

    Factors related to ETT: it included questions about type of ETT, route of intubation, and ETT fixation method.

    Part III:

    Factors related to PICU environment: it included questions about nurse/child ratio, monitoring devices if were available and functioning or not, ETT if was traced by the MV circuit or not, and MV circuit position.

    Part IV:

    Factors related to assigned nurse and care of child: it included questions about level of education and years of experience of assigned nurse, transfer of child to other site, handling of child during the performance of procedures, nurse shift during data collection, and documentation of ETT sheet.
  3. Observational checklist:

    This tool was used to observe nurses during securing ETT, which was adapted from Lynn and LeBon (2011). It includes 19 items about standardized technique of ETT securing, such as identifying the child; ETT depth and size; obtain the assistance of a second individual to hold the ETT in place while the old tape is removed and the new tape is placed; auscultate lung sounds; and assessment for cyanosis, oxygen saturation, chest symmetry, and stability of ETT.


Scoring system of checklists

The score of each item was rated as follows: two grades for completely done, and one grade for done incompletely. The total score of all practices was 38 grades. The total score of all practices was collected and distributed as follows:
  1. Done completely more than 75% of the total score.
  2. Done incompletely 65–75%.
  3. Poorly done less than 65%.


Tools validity

The tools were given to a group of three experts in the field of pediatric nursing medicine and pediatrics to test the content for clarity, relevance, applicability, and comprehensiveness, and minor modifications were done.

Reliability of the rating scale

Reliability of the second tool was tested statistically using Cronbach’s alpha, to ensure its consistency; it was 0.7, which means acceptable internal consistency and reliability.

Pilot study

The pilot study was carried out on 10 children of the total sample to test study tools in terms of its clarity, applicability, and time required to fulfill it. The needed modifications were done, and then the final formats were developed. The pilot study sample was included in the study.

Ethical consideration

A primary approval was obtained from the research ethical committee in the Faculty of Nursing, Cairo University. A written informed consent was obtained from the assigned nurse of an intubated child after complete description of the purpose and nature of the study to obtain their acceptance as well as to gain their cooperation. They were informed about their voluntary participation and their right to withdrawal from the study at any time. Moreover, nurses were assured that all gathered information would be kept confidential and used only for the purpose of the study. Oral approval was obtained from parents of children as recommended by ethical committee because the study had no intervention for children.

Procedure

An official permission was attained from the directors of Cairo University Specialized Pediatric Hospital and Pediatric University Hospital as well as the heads of PICUs. Research investigator calculated ETT depth by using the Pediatric Advanced Life Support guidelines and compared it with ETT cm. marking at the lip of child to determine if ETT is properly fixed or not. The personal data questionnaire of children, which included age, sex, and medical diagnosis, was fulfilled from medical sheet. The assessment sheet of factors affecting fixation of ETT in PICU took from 30 to 45 min to be fulfilled. The research investigator observed the assigned nurse during securing ETT using observational checklist. The research investigator was available for data collection 3 days/week and 5 h each day at different shifts (morning, afternoon, and night shift). The data were collected during the duration of 6 months from January to June 2017. Children connected to tracheostomy were excluded from the study.

Statistical analysis

The collected data were tabulated and summarized using statistical package for social studies, version 21 (SPSS is a program for statisitics analysis, first used at 1960 and used in USA at 1970 by David Muxworthy). Data were computerized and analyzed using appropriate descriptive and inferential statistical tests. Quantitative data were expressed as frequency and percentage. A comparison between qualitative variables was carried out by using parametric χ2 test. Correlation among variables was done using Pearson correlation coefficient. Statistical significance was considered at P value less than 0.05.


  Results Top


The study results revealed that more than half of the children (54.50%) had proper fixed ETT, whereas more than two-fifths of the children (45.5%) had improperly fixed ETT. More than two-thirds (62.4%) of the intubated children were males. More than half of the children (52.5%) were aged less than 1 year, 8.9% are from above 1 year to 3 years old, 16.8% are from above 3 years old to 6 years old, and 21.8% are above 6 years to 12 years old ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
Figure 1 Fixation of ETT among children. ETT, endotracheal tube.

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Figure 2 Children sex in the study sample.

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Figure 3 Children age among the study sample.

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Figure 4 Common risk factors of improper ETT fixation. ETT, endotracheal tube.

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[Table 1] highlights that 41.8% of the children with properly fixed ETT were less than 1 year, and more than two-fifths of them (43.6%) were female. Regarding education of the assigned nurse, more than half of the children (54.5%) received care from diploma nurses and majority (87.3%) received care from nurses with more than 2 years of experience in PICU. On the contrary, in children with improperly fixed ETT, more than two-thirds of them (65.2%) were younger than 1 year and more than two-thirds of the children (69.6%) were males. In addition to that, more than half of the children with improperly fixed ETT (52.2%) received care from technical nurses and received care from nurses with experience in PICU for less than 2 years. The same table shows that there are statistically significant differences between children with properly and improperly fixed ETT regarding nurses’ education and years of experiences, whereas there are no statistically significant differences with child age and sex.
Table 1 Relationship between fixation of endotracheal tube and personal characteristics of children and assigned nurses

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[Table 2] delineates that more than two-fifths of children (43.8%) with properly fixed ETT weighed between 10 and 20 kg. More than two-thirds of them (61.8%) stayed in PICU for less than 1 week. Slightly less than three-quarters of them (72.7%) were connected to MV for less than 1 week. Slightly less than two-thirds of them (58.2%) had received sedation, and nearly one-third of the children (30.9%) had been restrained. In addition, the same table shows that most of those children (87.3%) had passive movements, and vast majority of them (92.7%) had no facial trauma. For conscious level, 70.9% of these children were comatosed. In addition, majority of them (87.3%) had appropriate position in bed and vast majority (96.4%) had no salivary secretions. Among children with improperly fixed ETT, 67.4% weighed less than 10 kg, and more than two-thirds of them (69.5%) stayed in PICUs for 1 week or more. In addition, more than half of them (58.7%) were connected to MV for 1 week or more. Regarding sedation, more than half (54.3%) received sedation, and 80.4% had not been restrained. Nearly two-thirds of these children (60.9%) had passive movements. There are statistically significant differences regarding PICU days, MV days, child movement, child position in bed, and salivary secretions.
Table 2 Differences between endotracheal tube fixation and factors related to children

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[Table 3] illustrates that two-fifths of children with properly fixed ETT (40%) were connected to cuffed ETT, and 69.1% of them were orally intubated. Regarding ETT fixation method, more than two-thirds of children (63.6%) had ETT fixed by adhesive tape without tube holder, and nearly one-third of them (29.1%) had ETT fixed with adhesive tape with tube holder. On the contrary, 78.3% of children with improperly fixed ETT had uncuffed ETT, and more than two-thirds of them (67.1%) were orally intubated. The vast majority of them (93.5%) had ETT fixed with adhesive tape without tube holder. There are statistically significant differences between the two groups regarding type of ETT and ETT fixation method.
Table 3 Relationship between endotracheal tube fixation and selected factors

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[Table 4] reveals that all nurses of properly fixed ETT children were assigned to one to two children, most of children (87.3%) with properly fixed ETT had traction of ETT, and majority of them (92.7%) had appropriate MV circuit position. On the contrary, nearly two-thirds of the children with improper fixed ETT (60.9%) had no traction of ETT and more than one-third of them (34.8%) had inappropriate MV circuit position. There is a highly significant difference regarding ETT traction MV circuit position.
Table 4 Relationship between endotracheal tube fixation and selected factors related to pediatric intensive care unit environment

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[Table 5] demonstrates that most children with properly or improperly fixed ETT (94.5 and 93.5%, respectively) had not been transferred to other site to receive any procedure. In addition to that, there was appropriate handling of two groups of children (87.3 and 67.4%, respectively), but approximately one-third of children with improperly fixed ETT (32.6%) had inappropriate handling during care. Near three-quarters of children with proper fixed ETT (74.5%) and 65.2% of children with improperly fixed ETT were in morning shift and approximately one-third of them (28%) were in the night shift. Retaping ETT had been done correctly in 49.1% of children with fixed ETT and 71.7% of children with improperly fixed ETT but done incompletely in nearly one-third of children with improperly fixed ETT (28.3%). Documentation in ETT chart had been done in 56.4% for children with fixed ETT, whereas not done for most children with improperly fixed ETT (87%). There are statistically significant differences between the two groups for all variables except for transfer of child to another site.
Table 5 Relationship between endotracheal tube fixation and selected factors related to care of child (N=101)

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  Discussion Top


The results of present study revealed that more than two-fifths of the sample of children had improperly fixed ETT. These results are supported by Miller et al. (2016) in a study titled ‘Factors associated with misplaced endotracheal tubes during intubation in pediatric patients,’ who found that the ETT was improperly fixed after standard clinical assessment in slightly less than two-thirds of patients intubated in a Pediatric Emergency Department.

Although the results of the current study indicated that there was no significance difference between fixation of ETT and age of child, high percentage of improper fixed ETT occurred in children younger than 1 year. This result was in consistency with other studies such as Miller et al. (2016), which found that younger patients are at higher risk of undetected ETT misplacement. Moreover, a study conducted by Vats et al. (2017) entitled ‘An airway risk assessment score for improper fixation and unplanned extubation for intensive care pediatric patients’ emphasized that most of children with improperly fixed ETT and unplanned extubation were less than 1 year and their percentages decrease with advancing age. In the same line, Silva et al. (2013) in a study titled ‘Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations’ reported that no statistically significant differences were found with respect to the age of patients with improper fixed ETT when compared with those with correctly fixed ETT.

Besides, these results are supported by Harris et al. (2016) in a study titled ‘Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement’ who mentioned that the peak incidence of improper fixation and malposition of ETT occurred in patients under 1 year old. They added that incidence decreased with advancing age. From the researchers’ point of view, this may be interpreted as infants have smaller area of face on which the tube can be secured. Furthermore, these patients frequently present with excessive secretions and psychomotor agitation.

The current study results clarify that more than two-thirds of the children with improperly fixed ETT were male; these results are in accordance with Razavi et al. (2013) who found that risk factors of improper fixation of ETT included male sex. Moreover, the current study findings reflect that more than half of the female children have properly fixed ETT. These results are congruent with Miller et al. (2016) who found that most children who had correctly placed ETT were female. This means that male children need more observation and physical assessment and examination after birth.

The current study demonstrates that most children with properly fixed ETT received care from nurses with 2 or more years of experience in PICU. On the contrary, more than half of the children with improperly fixed ETT received care from nurses with experience in PICU for less than 2 years. Moreover, the results of the current study revealed that there is a highly statistically significance difference between assigned nurse experience and ETT fixation. These results are congruent with Norridge and While (2016) in a study entitled ‘The impact PICU nursing expertise on a child’s unplanned extubation’ who proved that the majority of slipped ETT and unplanned extubation occurred when pediatric patients were looked after by junior nurses with experience of less than 2 years in PICUs. They added that there is a highly statistically significant difference between assigned nurse experience and incidence of improper ETT fixation and unplanned extubation.

In addition to that, these results are in the same line with Robert et al. (2015), who in a study titled as ‘Multicenter analysis of the factors associated with unplanned extubation in the PICU’ highlighted that children with improperly fixed ETT received care from nurse recruited from another unit with no experience in PICU. Moreover, Da Silva and Fonseca (2017) in a study titled ‘Factors associated with unplanned extubation in children: a case–control study’ revealed that in-charge nurse experience less than 2 years was one of the important risk factors of slipped ETT and unplanned extubation. According to researchers’ interpretation, the assigned nurse must have not only knowledge of anatomical, physiological, and pathological features related to the airway but also needs experience about practical points in maintaining proper ETT fixation.

The findings of the current study demonstrated that more than half of the children who had properly fixed ETT weighed more than 10 kg. On the contrary, more than two-thirds of children with improperly fixed ETT weighed less than 10 kg, and the number of these children decreases with the increase in weight. These results were congruent with Silva et al. (2013), Razavi et al. (2013), Miller et al. (2016), and Vats et al. (2017), who reported that the relation between child weight and fixation of ETT is controversial. This could be owing to a smaller body surface on which the ETT can be secured.

Regarding stay in PICU and on MV, the findings of the present study identified that more than half of children with correctly fixed ETT stayed in ICU for less than 1 week and slightly less than three-quarters of them were connected to MV for less than 1 week. On the contrary, most children with improperly fixed ETT stayed in PICU and connected to MV for more than 2 weeks, and these differences are statistically significant. These results are supported in a prospective cohort study by Silva et al. (2013) of unplanned extubation in a PICU and in another study by Kanthimathinathan et al. (2015) and Vats et al. (2017) who reported that every day on PICU and on MV increased the risk of improper fixation of ETT and unplanned extubation by 3%, as well as authors reported that there were statistically significant differences between improper ETT fixation and PICU days and MV days. The research investigator observed that most children connected with ETT for more than 2 weeks had impaired facial skin integrity, and this could affect ETT stability.

The study results revealed that slightly less than two-thirds of children with properly fixed ETT received sedation. On the contrary, nearly half of the children with improper fixed ETT had not received sedation. These results are in the same line with Fitzgerald et al. (2015) in a study of the factors associated with unplanned extubation in the PICU, as they found that children with inadequate sedation were a risk factor for incorrectly fixed ETT. In addition, a case–control study by Da Silva and Fonseca (2017) proved that continuous sedation infusion was associated with proper ETT fixation. These results could be owing to that sedation decreases agitative movement of children.

The findings of the current study revealed that two-thirds of the children with properly fixed ETT are restrained, whereas more than three-thirds of the children with improperly fixed ETT are not restrained. In addition, there are no statistically significant relation between ETT fixation and use of restraining. In the same context, Razavi et al. (2013) reported that despite there not being statistically significance difference regarding the use of restraining, more than one-third of children who had improperly fixed ETT were not restrained. On the contrary, these results were inconsistent with Da Silva and Fonseca (2017), who emphasized that use of physical restraints was one of the risk factors of improper ETT fixation as a result of child agitation and reported that there was statistically significance difference regarding restraining. From the research investigators’ point of view, restraining decreases intentional and unintentional movement of children and decreases the risk of ETT dislocation, but at the same time, providing the child a period of rest from restraining, under close observation, is important to decrease child agitation.

The current study results proved that most of children with passive movements had properly fixed ETT, whereas more than one-third of children with improperly fixed ETT had active movements. This could be interpreted as child movement caused traction of ETT and MV connections, and this affects proper ETT fixation. These results are consistent with Razavi et al. (2013), who reported that moving patient with extreme care could significantly maintain proper ETT fixation and decrease the risk of unplanned extubation. Moreover, these results are in the same line with Da Silva and Fonseca (2017) who reported that child agitation and movement were most frequent factors affecting ETT fixation. In addition, these results are in accordance with the results of a recent study ‘Preventing unplanned extubation in the pediatric intensive care unit’ done by Bill et al. (2019) who mentioned that most intubated children who had incorrectly fixed ETT and unplanned extubation had active movements and restlessness.

The study results showed that more than two-thirds of children with properly fixed ETT were comatose, whereas nearly one-third of children with improperly fixed ETT were fully conscious. These results are congruent with

Da Silva and Fonseca (2017) who reported that a high level of consciousness seems to be highly related to improper ETT fixation. The study results found that nearly three-thirds of children with properly fixed ETT were in appropriate position in bed, whereas more than one-third of children with improperly fixed ETT were in inappropriate position in bed. These results were supported by Oliveira et al. (2012) in a study titled ‘Incidence and primary causes of unplanned extubation in a neonatal intensive care unit’ who reported that inappropriate positioning of children in beds was the cause of ETT misposition of cases.

The findings of the current study showed that most children with cuffed ETT had correct ETT fixation. On the contrary, approximately three-thirds of children with improperly fixed ETT had uncuffed ETT, and there is a highly significant association between ETT fixation and type of ETT. These results are in the same line with a meta-analysis study by Chen et al. (2018) titled ‘Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis,’ which demonstrated that cuffed tubes are safely used in children and discussed that uncuffed ETTs increased the need for tube changes, and cuffed tubes may be an optimal option for pediatric patients. In addition, it added that there was a statistically significance difference regarding type of ETT (cuffed or uncuffed ETT). From researchers’ point of view, inappropriate size of the uncuffed ETT might be the main cause leading to improper ETT fixation in these pediatric patients and cuffed ETT provides more internal stability of ETT.

The current study results illustrated that despite there being no statistically significant difference between ETT fixation and route of intubation, more than one-third of the children with properly fixed ETT were nasally intubated and more than two-thirds of the children with improperly fixed ETT were orally intubated. These results were consistent with Kanthimathinathan et al. (2015), as they concluded that nasal intubation decreased the risk of improper fixation of ETT and unplanned extubation. Moreover, it may be attributed to that oral intubated children may be more restless than nasal one.

The findings of the present study identified that most children with ETT fixed with adhesive tape with tube holder had properly fixed ETT. On the contrary, vast majority of the children with improperly fixed ETT had ETT fixed with adhesive tape without tube holder. These results were in accordance with Buckley et al. (2016), who conducted a study entitled ‘A comparison of the Haider tube-guard endotracheal tube holder versus adhesive tape to determine if this novel device can reduce endotracheal tube movement and prevent unplanned extubation’ and proved that the tube holder was superior to adhesive tape in securing the ETT. Moreover, these results are in the same line with Fisher et al. (2014), who reported that ETT holders exert less force on a patient’s face and improve ETT fixation. From the research investigators’ point of view, tube holder device significantly reduced ETT movement, may prevent traction of ETT, and can help secure the tube place after insertion.

The present study results found that there was no relation between ETT fixation and transfer of children. These results are contradicted by Brust et al. (2011) in a study titled ‘Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU,’ in which pediatric patients were intubated before transfer from an outside hospital to a tertiary PICU, and it found that patients had improperly fixed ETT after arrival. In addition, these results are in accordance with results of collaborative, hospital-based quality-improvement project to reduce the rate of unplanned extubation in the PICU conducted by Tripathi et al. (2015) who mentioned that all children had improper ETT fixation and unplanned extubation during transfer and nursing procedures. From researchers’ point of view, the results of current study may be because majority of intubated children had not been transferred outside PICU. Moreover, mostly there was no need for transfer and radiograph was done in PICU.

The present study results also clarified that slightly less than three-thirds of the children with properly fixed ETT were handled properly during care, whereas more than one-third of the children with improperly fixed ETT were handled improperly during care. These results are in accordance with Loganathan et al. (2017), who conducted a study titled ‘Quality improvement study on new endotracheal tube securing device (Neobar) in neonates’ and proved that handling of children during performance of other procedures was a risk factor associated with improperly fixed ETT and unplanned extubation.

The current study results clarify that regarding nurse shift during data collection, vast majority of children with improper fixed ETT were in morning shift. These results are supported by Meregalli et al. (2013), who highlighted that the highest percentage of improper fixation and unplanned extubation occurred during the morning nurse shift on working days. These results are contradicted with Da Silva and Fonseca (2017), who reported that night shift was one of the risk factors of improper fixation and unplanned extubation. From the research investigators’ point of view, improper fixation of ETT is more common during the morning shift because children are subjected to more procedures.

The study results revealed that checklist of securing ETT had been done correctly in slightly less than half of the children with properly fixed ETT, whereas incompletely in nearly one-third of the children with improperly fixed ETT. These results agree with Loganathan et al. (2017), who reported that incorrect retaping/adjustment of ETT was the common factor associated with improperly fixed ETT and unplanned extubation. In addition, Meregalli et al. (2013) identified that the most common causes of improper ETT fixation and unplanned extubation were incorrect ETT fixation procedure and incorrect retaping procedure. Additionally, these results are in the same line with findings of a recent study by Bill et al. (2019), who emphasized that improper ETT retaping and securement was one of causes of improper fixed ETT in PICU. The research investigators observed that the assigned nurse did the procedure of ETT retaping alone without assistance from another nurse. In addition, most nurses caring for children did not check ETT position before retaping and did not document ETT card after first intubation.

The findings of the current study showed that documentation of ETT chart had been done in more than half of the children with fixed ETT, whereas not done for most children with improperly fixed ETT. There was a highly statistically significant difference between ETT fixation and documentation of ETT card. These results were in the same line with Tiernan and Clerkin (2016) who recommended that documentation procedure in the nursing notes including size and type of ETT and length to nose or lips is important to maintain fixation of ETT and to ensure continuity of care. The current study results answered the research question about factors affecting ETT fixation among children in PICU.


  Conclusion Top


In the light of study findings, absence of salivary secretions in child mouth was the most frequent finding in children with properly fixed ETT followed by appropriate MV circuit position, appropriate child position in bed, experience of the assigned nurse of more than 2 years in PICU, passive movement of child, no traction of ETT, and appropriate handling of child. On the contrary, ETT fixation with adhesive tape without tube holder was the most frequent finding in children with improperly fixed ETT followed by no documentation of ETT card, uncuffed ETT, morning shift, stay in PICU more than 2 weeks, MV days more than 1 week, and nurse’s experiences in PICU less than 2 years.

Recommendations

  1. Standard method of fixation of ETT should be used in all children by adhesive tape with tube holder.
  2. ETT position should be checked and documented with every nursing shift.
  3. Regular suctioning is recommended to ensure proper ETT fixation.
[26]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bill B, Vickie S, Jennifer S, Wilson A (2019). Preventing unplanned extubations in the pediatric intensive care unit. Crit Care Med 47:687.  Back to cited text no. 1
    
2.
Brust P, BrownIII CA, Berg RA, Walls RM, Sarouhas NT, Nadkarni VM (2011). Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU. Resuscitation 82:386–390.  Back to cited text no. 2
    
3.
Buckley JC, Brown AP, Shin JS, Rogers KM, Hoftman NN (2016). A comparison of the haider tube-guard® endotracheal tube holder versus adhesive tape to determine if this novel device can reduce endotracheal tube movement and prevent unplanned extubation. Anesth Analg 122:1439–1443.  Back to cited text no. 3
    
4.
Chameides L, Kleinman ME, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL et al. (2011) Part 14: pediatric advanced life support: 2011 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122(18 Suppl 3):S876–S908. https://doi.org/10.1161/CIRCULATIONAHA.110.971101  Back to cited text no. 4
    
5.
Chen L, Zhang J, Pan G, Li X, Shi T, He W (2018). Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis. Open Med (Warsaw, Poland) 13:366–373.  Back to cited text no. 5
    
6.
Christopher N, Shekhar V, Douglas W, Kathleen M, Rick H, Dean J et al. (2019). Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 10:1–11.  Back to cited text no. 6
    
7.
Da Silva PSL, Fonseca MCM (2017). Factors associated with unplanned extubation in children: a case-control study. J Intensive Care Med 35:74–81.  Back to cited text no. 7
    
8.
Fisher DF, Chenelle CT, Marchese AD, Kratohvil JP, Kacmarek RM (2014). Comparison of commercial and non-commercial endotracheal tubesecuring devices. Respir Care 59:1315–1323.  Back to cited text no. 8
    
9.
Fitzgerald RK, Davis AT, Hanson SJ (2015). Multicenter analysis of the factors associated with unplanned extubation in the PICU. Pediatr Crit Care Med 16:e217–e223.  Back to cited text no. 9
    
10.
Ahmed RA, Boyer TJ (2020). Endotracheal Tube (ET) [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539747  Back to cited text no. 10
    
11.
Harris EA, Arheart KL, Penning DH (2016). Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement. Can J Anesth 55:685–690.  Back to cited text no. 11
    
12.
Kanthimathinathan HK, Durward A, Nyman A, Murdoch IA, Tibby SM (2015). Unplanned extubation in a paediatric intensive care unit: prospective cohort study. Intensive Care Med 41:1299–1306.  Back to cited text no. 12
    
13.
Loganathan K, Nair V, Vine M, Kostecky L, Kowal D, Soraisham A (2017). Quality improvement study on new endotracheal tube securing device (Neobar) in neonates. Indian J Pediatr 84:20–24.  Back to cited text no. 13
    
14.
Lynn P, LeBon M (2011). Taylor’s clinical nursing skills. 3rd ed. Securing An Endotracheal Tube. NewYork: Lippincott Williams & Wilkins; 397–399.  Back to cited text no. 14
    
15.
Meregalli CN, Jorro Barón FA, D’Alessandro MA, Danzi PE, Debaisi GE (2013). Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit. Arch Argent Pediatr 111:391397.  Back to cited text no. 15
    
16.
Miller KA, Kimia A, Monuteaux MC, Nagler J (2016). Factors associated with misplaced endotracheal tubes during intubation in pediatric patients. J Emerg Med 51:9–18.  Back to cited text no. 16
    
17.
Nina C, Cindy B, Richard I, Kelly R, Michael R, Jon K (2020). Achieving sustainability in reducing unplanned extubations in a pediatric cardiac ICU. Pediatr Crit Care Med 21:350–356.  Back to cited text no. 17
    
18.
Norridge M, While AE (2016). The impact PICU nursing expertise has on a child’s unplanned extubation. Nurs Crit Care 21:295–303.  Back to cited text no. 18
    
19.
Oliveira PCR, Cabral LA, Schettino RC, Ribeiro SNS (2012). Incidence and primary causes of unplanned extubation in a neonatal intensive care unit. Rev Brasil Terap Intensiva 24:230–235.  Back to cited text no. 19
    
20.
Razavi SS, Nejad RA, Mohajerani SA, Talebian M (2013). Risk factors of unplanned extubation in pediatric intensive care unit. Tanaffos 12 (3):11–16.  Back to cited text no. 20
    
21.
Robert KF, Alan TD, Sheila JH (2015). Multicenter analysis of the factors associated with unplanned extubation in the PICU. Pediatr Crit Care Med 16:e217–e223.  Back to cited text no. 21
    
22.
Roddy DJ, Spaeder MC, Pastor W, Stockwell DC, Klugman D (2015). Unplanned extubations in children: impact on hospital cost and length of stay. Pediatr Crit Care Med 16:572–575.  Back to cited text no. 22
    
23.
Silva PS, Reis ME, Aguiar VE, Fonseca MC (2013). Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations. Respir Care 58:1237–1245.  Back to cited text no. 23
    
24.
Tiernan E, Clerkin R (2016). Guideline for nurses on assisting with intubation and extubation of infants and children. Available at: https://www.olchc.ie/Healthcare-Professionals/Nursing-PracticeGuidelines/Intubation-Extubation-2016.pdf  Back to cited text no. 24
    
25.
Tripathi S, Nunez DJ, Katya C, Ushay HM (2015). Plan to have no unplanned: a collaborative, hospital-based quality-improvement project to reduce the rate of unplanned extubations in the pediatric ICU. Respir Care 60:1105–1112.  Back to cited text no. 25
    
26.
Vats A, Hopkins C, Hatfield KM, Yan J, Palmer R, Keskinocak P (2017). An airway risk assessment score for unplanned extubation in intensive care pediatric patients‏. Pediatr Crit Care Med 18:661–666.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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