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• W4298120001 abstract "Q What is the preferred method for endotracheal tube (ETT) securement during prone positioning to prevent pressure injury (PI)?A Maureen A. Seckel, APRN, ACNS-BC, CCNS, CCRN-K, and Dannette A. Mitchell, MSN, APRN, ACNS-BC, CCRN, reply:Since the PROSEVA (Proning Severe ARDS Patients) study in 2013,1 prone positioning has been an evidence-based therapeutic intervention used to improve oxygenation and outcomes in patients with moderate to severe acute respiratory distress syndrome (ARDS) receiving mechanical ventilation.2-4 During the COVID-19 pandemic, the use of prone positioning in intensive care units has increased dramatically because of the large influx of patients who have benefit-ted from this intervention. Prone positioning is now recognized as an evidence-based recommendation for patients with COVID-19 and ARDS receiving mechanical ventilation.5-7 Health systems have quickly developed and implemented protocols and policies to guide prone positioning, leading to many questions about how to prevent PIs and, specifically, what is best practice for ETT securement.One of the most common complications of prone positioning is the development of PIs; the head and neck are the most frequently reported PI locations,8-13 with a reported incidence of 43%.14 Many factors lead to increased risk for and incidence of PI during prone positioning, including weight, hemodynamic status, comorbidities, length of time in prone position, devices, and surfaces.14-19Endotracheal tube securement and care are necessary for all patients undergoing endotracheal intubation. Currently, there are commercial ETT securement devices as well as tape or ties that are used to secure ETTs (Table 1).20 Two commercial devices include PI warnings regarding prone positioning or having the head in the side-lying position21 or recommendations for frequent assessment, repositioning the ETT often, and supporting the ventilator tubing to relieve pressure.22 In the AACN Procedure Manual for High Acuity, Progressive, and Critical Care, commercial ETT securement devices are not recommended because of the increased risk of PI.23 Several guidelines recommend removing the commercial ETT securement device before prone positioning and replacing it with tape.15,16,24,25 Recent guidelines for PI prevention for prone positioning include specific recommendations to prevent facial injuries (Table 2).16Several recent articles have made varied recommendations about ETT securement devices with conflicting results.13,26-28 Johnson and colleagues26 used prone positioning for 130 patients with COVID-19; they added a certified wound and skin nurse to their prone-positioning team, which resulted in 2 of 52 patients (3.8%) in the intervention group having PIs versus 18 of 78 patients (23%) in the comparison group. In addition to the commercial securement device, the authors reported using a foam dressing under the device (Kari A. Mastro, PhD, RN, MBBS, email communication, March 3, 2022). In a retrospective review of 143 patients with COVID-19 undergoing prone positioning, 68 (47.6%) patients had facial PIs, with the cheeks being the most common site (57 PIs).13 A formal protocol for prevention of facial PI was developed during the study and included the application of a foam dressing under the device.13 In another retrospective analysis, investigators found that development of and education on a prone-positioning protocol for 36 patients with ARDS resulted in zero PIs.27 The authors found that the ability to move the ETT from side to side with the commercial securement device during head turns was an important feature of this protocol (Patrick Ryan, RN, CNS, email communication, March 14, 2022). Sleiwah and colleagues28 identified facial PIs in a cohort of patients with COVID-19 and found that in 12 of 16 patients, the PIs were related to prone positioning, which had been performed with the use of 2 different commercial devices.In a small quality improvement study of simulation training for prone positioning, 1 of 9 patients (11%) developed a facial PI on the lip with the protocol of changing to tape securement from commercial securement devices before prone positioning (Yogesh Apte, MBBS, email communication, March 8, 2022).9 Binda and colleagues8 reported a total of 28 PIs in 63 patients with COVID-19 who were placed in the prone position. There were 13 facial PIs in 16 (37%) patients who had received a combination of hydrocolloid dressing and surgical tape (Filippo Binda, MSN, CCRN, email communication, March 5, 2022). In a retrospective study of 61 patients with prolonged prone positioning greater than 24 hours, investigators found that 27 (44.6%) patients had PIs on the face, chin, nose, or neck.10 The standard of practice in this study was to secure the ETT with tape before prone positioning and to pad the back of the neck with foam dressings or tracheal ties to prevent head edema.29Many previous prone-positioning studies do not denote what their procedure is for ETT securement along with metrics for facial PIs; therefore, it is difficult to draw conclusions. More research is needed with larger patient populations and clear description of the measures used to prevent PIs. Endotracheal tube securement methods include using tape or tie securement with silicone foam or other pressure-prevention dressings, commercial ETT securement devices, or prophylactic dressings under commercial devices. In a recent review and gap analysis, investigators studied the current evidence regarding PI prevention recommendations for patients placed in the prone position and identified a lack of easily accessible evidence-based guidelines.30 Although many health care systems have prone-positioning protocols in place, ETT holder information and PI metrics are not always included or known. Your health care system should have a prone-positioning protocol or process in place that is based on the best evidence and clearly delineates PI prevention with attention to ETT securement and metrics. A strategy for educating team members to ensure protocol adherence is also required." @default.
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• W4298120001 date "2022-10-01" @default.
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• W4298120001 title "Securing Endotracheal Tubes During Prone Positioning" @default.
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