Tips on securing a nasal ETT! and other advise :)

  1. 0
    Hi all,

    I am currently working full time as a paramedic and am looking for any good tips on securing nasal tubes. I also have a couple other questions.

    I had a male patient last night that I had to nasally tube secondary to respirtory failure from CHF... Needless to say the nare bled making the patient's face wet, he was also very diapheretic making securng the tube with tape difficult. I tried drying the area, but that didn't help. I basically had to have one of the EMTs hold it the entire time. I was happy that I got the nasal tube since that was only my second time ever attempting one, but it was very difficult to keep it in place especially once the patient woke up fighting prior to sedation and during the 2 floor carry down! We cannot RSI iin my system so no sedation until the tube is in.

    I tried orally intubating him, but I goosed it, which of course added to the headache with vomiting now mixing in with the pulmonary edema. DOH! We had suction ready and I was able to hold his head to the side so I do not think he aspirated any. He also of course woke up after some BVM ventilations temporarily making oral intubation more difficult since his gag returned and his RR picked up. I tried oral intubation, but could not see the cords or even cartlidge despite him being in the sniffing position, but he was also not relaxed any longer. I tried a boogie, but I could not get it to go into the trachea, kept going right into the esophagus. I am not sure if he was just really anterior or what. The nasal tube was a pecie of cake, but I would think if he was that anterior that I would have had trouble with that as well????

    Also I have very small hands (small gloves are loose on me) and I read somewhere that people with smaller hands sometimes do better using a pedi handle even on adult patients... Do any of you know if this is true?

    Thanks for any help!

    Happy
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  4. 11 Comments so far...

  5. 0
    Hmmm...use roller gauze, loop it around the tube, then loop it around his head?
  6. 1
    I would recommend using a cloth tie wrapped around the ETT and then secured by tying it around the patient's head. Alternatively, you can use silk tape by wrapping it completely around the ETT then completely around the head of the patient and back around a couple of times.

    You should use whatever intubating handle feels comfortable for you.
    mskate likes this.
  7. 0
    Hi. I'm not a CRNA, any of them good provide a wealth of good advice but the title of your post intrigued me.
    You can secure a nasal ETT with tape, similar to an oral tube, but having the EMT hold it in place is fine because the tube isn't going to stay in the nares for very long once you get to the ER.
    I have a couple questions for you (and I wasn't on your call, so please don't interpret this as second guessing you):
    what made you decide the patient was in respiratory failure? this diagnosis is usually made based on ABG results. Patients can present dramatically (semi-conscious, tachypneic, low spo2, etc) but respond well to other treatment modalities without needing to be intubated.
    You mention your system does not carry RSI medications, do you use CPAP/BiPAP? This is an excellent device that recruits more areas of lung tissue and also creates pressure to "push out" pulmonary edema. Often a BiPAP trial may preceed a blood gas to determine whether or not a patient is in failure and requires mechanical ventilation.
    knowing when NOT to intubate a patient is much more important than learning the skills involved with passing a tube. It sounds like you were on a tough call, especially carrying the man down 2 flights of stairs while he was combative and tried to remove the tube!!
    Was he in fulminant edema when you made initial contact?
    If you have an opportunity, you should ask the ER physician what the disposition was and see a copy of the blood gas upon your arrival.
    and, about the pedi-handle, use whatever is most comfortable. I've intubated ~300 cases in my career and my favorite is a Wisconsin #2.
  8. 0
    Cloth tape, tie a clove hitch around the tube, then secure behind their head. It won't slip if you pull the clove hitch tight enough to bit into the plastic a little bit.
  9. 0
    Quote from getoverit
    Hi. I'm not a CRNA, any of them good provide a wealth of good advice but the title of your post intrigued me.
    You can secure a nasal ETT with tape, similar to an oral tube, but having the EMT hold it in place is fine because the tube isn't going to stay in the nares for very long once you get to the ER.
    I have a couple questions for you (and I wasn't on your call, so please don't interpret this as second guessing you):
    what made you decide the patient was in respiratory failure? this diagnosis is usually made based on ABG results. Patients can present dramatically (semi-conscious, tachypneic, low spo2, etc) but respond well to other treatment modalities without needing to be intubated.
    You mention your system does not carry RSI medications, do you use CPAP/BiPAP? This is an excellent device that recruits more areas of lung tissue and also creates pressure to "push out" pulmonary edema. Often a BiPAP trial may preceed a blood gas to determine whether or not a patient is in failure and requires mechanical ventilation.
    knowing when NOT to intubate a patient is much more important than learning the skills involved with passing a tube. It sounds like you were on a tough call, especially carrying the man down 2 flights of stairs while he was combative and tried to remove the tube!!
    Was he in fulminant edema when you made initial contact?
    If you have an opportunity, you should ask the ER physician what the disposition was and see a copy of the blood gas upon your arrival.
    and, about the pedi-handle, use whatever is most comfortable. I've intubated ~300 cases in my career and my favorite is a Wisconsin #2.

    I am quite comfortable with my ability to judge when a patient is in respiratory failure sine i have 13 years of EMS experience, as well as a few of ER nursing experience.

    This patient was WAY beyond CPAP which we carry and I am well aware of how well it works, but when a patient has a sat of 70 with a good wave form and is on non rebreather just prior to turning cyanotic, becoming unresponsive, and bradying down to the 20s from hypoxia. just as the FD was about to put him on CPAP and as we weere getting to him. yeah CPAP isnt gonna do it. We bagged him and his HR cam up to the 70s still relative bradycardia , but thr patient was still quite hypoxic with gasping respirations, unresponsive without a gag. the desicion to intubate was made and an appropriate one at that. Patient only awoke after being vetilated for several minutes. He was so full of pulmonary edema it was foaming out of the tube!

    Thank you for your suggestion, but intubating this patient was appropriate. This pt has a hx of flash pulmonary edema and last time I had him CPAP worked awsome, but he was awake and alert and mentating well and a lot less hypoxic!


    Happy
  10. 0
    tube tie / conforming bandage ....

    handle and blade choice are to some degree a provider dependent option ...
  11. 0
    I never implied it was inappropriate to intubate and your second description of the patient was much more detailed than the first.
    and the "foaming out of the ET tube" is the fulminant edema I was asking about.
  12. 0
    For starters, I'm a trauma/military CRNA. I would first be cautious (no offense at all) with your lingo. You didn't "goose" anything. You placed the endotracheal tube in the esophagus. Next, you didn't dilate. If you feel there is ANY chance of having to place a Nasal ETT, then dilate the nares with nasal airways ASSUMING the patient is not actively desaturating or not an RSI. How we secure the nasal endotracheal tubes in Afghanistan in preparation for a long flight out of the country for a ventilated patient is........

    1. Mastisol
    2. String/Fine Cord/Even a Stylet that is bent that's secured around the patients NETT or ETT and wrapped around their neck. Place 4x4's between their neck and the cord/string/or bent stylet. Remember, the ETT/NETT goes passes the vocal cords, so you can't strangle them by placing the string in a pretty secure manner around their neck. Afterall, the ETT extends directly into the trachea.
    3. Paralytics AFTER you are 100% sure the NETT or ETT is in place! Meaning....long term muscle relaxants for transport such as VEC, ROC, Cis. Don't let the patient cough and dislodge the tube.

    The above is only my advice to you.
  13. 0
    Quote from getoverit
    knowing when NOT to intubate a patient is much more important than learning the skills involved with passing a tube. .
    I have to disagree a bit. It should not be a matter of knowing when NOT to intubate, but rather WHEN to intubate. And i think there IS a difference. In fact I taught my paramedic students to evaluate EVERY patient FIRST as to whether they needed intubating..or maybe we should say 'airway intervention' since there are a number of airway adjuncts and procedures to choose from these days. Early intubation in cardiogenic pulmonary edema, esp. fulminating, is likely one of the life saving and outcome improving pre-hospital uses of the endotracheal tube. It most often must be accomplished with a breathing fighting patient via the nasal route and it is truly an art as much as a skill. the patient should be sitting straight up...accommodate their desired position to get air... talk them thru it....tell them the tube will be uncomfortable but will help them breath easier..

    U move WITH the patient to ease it in...talking the whole time. There is often little opportunity for niceties like serial dilations, neosynepherine soaked gauze, etc. These patients, in this extremis, if not nasally intubated will quickly tire, become severely hypoxic and will race you to their arrest before you can orally intubate them once they become so hypoxic they have little gag reflex. when the OP was describing his run I went back in my mind 20 years to my medic days and a particular patient who I was certain was vomiting through their nasal ET I just placed before I quickly realized that that huge amount of pink liquid was from the lungs.

    After the nasal use whatever PPV you have working with their resp rate...hyperventilate them, u soon overpower their resp drive and they relax from exhaustion and let you ventilate them. As long as they are hypoxic however they will fight you and the tube. Bag the crap outta them before taking them down the stairs etc.

    Either trach cloth "tape" or kling to secure the tube around the entire head.


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