Endotracheal Tube and Oral Care
PREREQUISITE NURSING KNOWLEDGE
• Anatomy and physiology of the pulmonary system should be understood.
• Anatomy and physiology of the oral cavity and the importance of evidence-based oral hygiene procedures on a regular basis should be understood.1,18,21,27,49,54
• Endotracheal (ET) tubes are used to maintain a patent airway or to facilitate mechanical ventilation. The presence of these artificial airways, especially ET tubes, prevents effective coughing and secretion removal, necessitating periodic removal of pulmonary secretions with suctioning.
• Oral care given every 2 to 4 hours appears to provide a greater improvement in oral health. If oral care is not provided for 4 to 6 hours, previous benefits are thought to be lost.10
• Suctioning of airways should be performed only for clinical indications and not as a routine fixed-schedule treatment (see Procedure 12). In acute care situations, suctioning is performed as a sterile procedure to prevent healthcare-acquired pneumonia.
• Adequate systemic hydration and supplemental humidification of inspired gases assist in thinning secretions for easier aspiration from airways.20,36,37,51
• Appropriate cuff care (see Procedure 13) helps prevent major pulmonary aspirations, prepares for tracheal extubation, decreases the risk of inadvertent extubation, provides a patent airway for ventilation and removal of secretions, and decreases the risk of iatrogenic infections.5,15,29,37,51
• Constant pressure from the ET tube on the mouth or nose can cause skin breakdown.
• If the patient is anxious or uncooperative, use of two caregivers for retaping or repositioning the endotracheal tube helps prevent accidental dislodgment of the tube.
• The incidence of ventilator-associated pneumonia (VAP) is increased in patients intubated for longer than 24 hours.36,37,51
• Nasotracheal intubation should be avoided because it increases the risk of VAP.37,51
• VAP is a risk factor for endotracheal intubation.
VAP is thought to be related to aspiration of gastric or oral secretions and colonization of the mouth related to dental plaque.14,18,19,37,38,51
VAP increases not only ventilator and intensive care unit (ICU) days and hospital length of stay, but also overall morbidity and mortality of the critically ill patient.33,37,39,41,44,47,51,55
EQUIPMENT
• Bite-block or oral airway if needed
• Adhesive or twill tape; commercial endotracheal tube holder (design must ensure ability to provide oral care and suctioning)
• 2 × 2 Gauze or cotton swab for cleaning around the nares
• Soft pediatric/adult toothbrush or suction toothbrush
• Toothettes/oral swab/oral suction swab
• Oral cleansing solution (e.g., 1.5% H2O2,3,18,31,44,47 chlorhexidine,3,6,9,16,22,23,26,34,52 cetylpyridinium chloride [CPC],3,30,43,50 toothpaste10,24,40)
Additional equipment, to have available as needed, includes the following:
• Closed-suction setup with a catheter of appropriate size (Table 4-1)
TABLE 4-1
Guidelines for Catheter Size for Endotracheal and Tracheostomy Tube Suctioning*
*This guide should be used as an estimate only. Actual sizes depend on the size and individual needs of the patient.
(From St John RE, Seckel MA: Airway management. In AACN protocols for practice: care of the mechanically ventilated patient series, ed 2, Aliso Viejo, CA, 2002, American Association of Critical-Care Nurses.)
• Sterile saline solution lavage containers for cleansing the closed suction system after use (5 to 10 mL)
• Suction catheter for oral and nasal suctioning (single-use Yankauer, covered Yankauer, disposable oral saliva ejector)
• Two sources of suction or a bifurcated connection device attached to a single suction source
PATIENT AND FAMILY EDUCATION
• Explain the procedure to the patient and family, including the purpose of ET tube care and the importance of comprehensive oral care in prevention of infection.1 
Rationale: This step identifies patient and family knowledge deficits concerning patient condition, procedure, expected benefits, and potential risks and allows time for questions to clarify information and voice concerns. Explanations decrease patient anxiety and enhance cooperation.
• If indicated, explain the patient’s role in assisting with ET tube care. 
Rationale: Eliciting the patient’s cooperation assists with care.
• Explain that the patient will be unable to speak while the ET tube is in place but that other means of communication will be provided. 
Rationale: This information enhances patient and family understanding and decreases anxiety.
• Explain that the patient’s hands may be immobilized to prevent accidental dislodgment of the tube. 
Rationale: This information enhances patient and family understanding and decreases anxiety.
PATIENT ASSESSMENT AND PREPARATION
Patient Assessment
• Verify correct patient with two identifiers. 
Rationale: Prior to performing a procedure, the nurse should ensure the correct identification of the patient for the intended intervention.
• Assess for signs and symptoms that indicate that oral cavity and ET tube care is necessary.
Excessive secretions (oral or tracheal)
Soiled tape or ties or commercial device
Patient biting or kinking tube
Pressure areas on nares, corner of mouth, or tongue
ET tube moving in and out of mouth
Patient able to verbalize or audible air leak around ET tube
• 
Rationale: Assessment provides for early recognition that oral or ET tube care is needed.
• Assess level of consciousness and level of anxiety. 
Rationale: This assessment determines the need for sedation during ET tube care and the number of care providers needed to perform the activities.
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise and reinforce information as needed. 
Rationale: This process evaluates and reinforces understanding of previously taught information.
• Maintain the patient in a semi-Fowler’s (≥30 degrees) position during mechanical ventilation to reduce the risk of aspiration.13,36,37,51,53 Assist the patient to a high Fowler’s position or the most comfortable position for both the patient and nurse before performing the care. 
Rationale: This position promotes comfort and reduces physical strain and maintains head of bed elevation to reduce risk of aspiration.13,20,36,37,51,53
References
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