Have you had this happen to you?

bethem · Sep 9, 2008

It has happened to me; we use bite blocks to ensure the patient can't bite, and do qshift tape changes during which we reposition the tube and the pilot line.

Good idea to check for snaggleteeth and other hazards to the tube though.

If you have artery forceps handy, you can put a bit of gauze around the pilot line above the level of the leak (if it's not in the pt's mouth) and clamp it off until you can get a tube change.

Creamsoda, ASN, RN · Sep 10, 2008

Actually, the other day, a patient on our unit bit through the ETT. So they extubated him and had to reintubate shortly after. Needless to say he got sedated after that.

blueheaven · Sep 10, 2008

It's happened to me too! As the OP said I you can take a pair of hemostats and put a bit of gauze around the pilot line above the level of the leak (if it's not in the pt's mouth) and clamp it off. Usually this happens after all of us have repeatedly told the doctors that they weren't being sedated enough and then (the docs) ignoring us.

seanpdent, ADN, BSN, MSN, APRN, NP · Sep 10, 2008

I echo the above comments. We utilize bite blocks for that very reason.

We had a pt bite the pilot balloon line... but he was from and outside hospital and did not have is head gear/bite block on.

:)

joeyzstj, LPN · Sep 11, 2008

It happens all the time. It is so likely to happen that the companies that make the ET tubes make a kit to fix it when this happens. There is absolutely nothing you can do in most cases to prevent it aside from using a bite block. Things like this just happen, and it regard to the ventilator, it shoud and in most cases will compensate for the leak. The problem is you wont get the same degree of lung expansion. Just in case you havnt seen one, the kit that is used to repair it consists of a new pilot balloon with a needle on the end. You cut below the damaged area and stick the needle in the part of the pilot tubing the you just cut. Reinflate the ET tube and youre good to go. In the case that this doesnt work or its been bitten off too far down to fix, its good to know what an eschman stick is or various other forms of tube exchangers. Using a "swizzle stick" as its often called, to change out an ET tube can get kinda hairy sometimes. Its always good to have either Anesthesia or two RT's at bedside before attempting to do this. about 50% of the cases Ive seen with tube changers required reintubation with a laryngoscope

Indy, LPN, LVN · Sep 12, 2008

I had a methadone overdose bite through the pilot line once, near the level of the lips. So we put the bite block in, retaped, (after sedating) and cut the end off the pilot line right where the leak was. Then the RT put a sliptip 10cc syringe in the line, jammed the tip in good, and taped the syringe to the ET tube to last till morning, when anesthesia would be available to help with a tube change.

Nurse Lulu · Oct 10, 2008

Actually, the other day, a patient on our unit bit through the ETT. So they extubated him and had to reintubate shortly after. Needless to say he got sedated after that.

US TOO!!!! ETOH, who had everything on board from haldol, ativan, versed,..... OMG I freaked out!!! CAT:eek:

RRT2RN2CRNA · Oct 16, 2008

Yes, it does happen on occasion (Usually on a pt that needs to be sedated more.) Sometimes it's a slow leak if the pt's been gnawing on it off and on. Sometimes they just chomp right through it and the cuff wont hold air at all. I also have had 2 nurses cut or nick the pilot line by mistake when trying to cut tapes re-securing the ETT. (Oops.)

Usually you'll know something's up when you get "low volume" alarm on the vent, and see that the exhaled tidal volumes are way lower than they're supposed to be. And you'll hear a big ol leak at the trachea.

We (RTs) have pilot line repair patch kits that sometimes can hold you over till the tube is changed. The line has to be bit pretty distal though- you have to be able to get at it. The patch kit looks like a little needle attached to a replacement pilot balloon.

(For other RTs on here wondering "how does that work?" I usually take the holey pilot line, pump it up, clamp it with a hemostat. Then I cut the old pilot balloon line cleanly with sharp scissors (distal to the clamp obviously), hold the pilot line with tweezers in my left hand, and then wiggle the needle into the lumen of the pilot line with my right hand. Sometimes it works, sometimes- not so much. I only use it when anesthesia is tied up, and I can't retube righ then bc I'd need drugs pushed.)

If I don't need drugs pushed, I will just switch out the tube with tube exchanger or a "bougie" - it's a long thin bendy stick basically that serves as a placeholder. You thread the bougie through down the old tube lumen, keep it there , lift the old tube out from around it- take the old tube out- bougie still in place. Then thread a new tube over the bougie back down the depth it was at before (there are markings on the side of the bougie). Or I just re-tube with a scope.

Moral of the story for you: Don't just silence the vent alarm and ignore the situation, or just randomly add air to the cuff. Most vents have alarm logs that will show what you're doing. Listen to the breath sounds and call respiratory so they can properly measure the cuff pressure, and check it out right away before it really affects the pt.

Don't be afraid to ask one of the nice RTs how anything works. Most will be happy to chat with you.

vivere · Oct 29, 2008

Yes, we had it happen with a patient. She bit clean through the cuff tubing....She was otherwise pretty debilitated, and the doctor suggested we just tape the tube in place well. Her sats remained about the same for the rest of the shift. We try to keep the patient sedated enough so that biting is not a problem, and for those patients who still somehow can get ahold of the tubing and try to bite down, we will use a bite block.

I had a boss tell me not too long ago that it was impossible for a patient to cough a tube out......but patients will try to dislodge a tube in any way possible a lot of the time. If the cuff has a leak, and the patient has a strong enough cough, AND if the tube is not secured well, you can bet the patient can dislodge the tube so that it is not in the proper place. And they can also extubate themselves while restrained, and sedated, by grabbing hold of the bottom section of tubing nearest the hand. There is no substitute for frequent assessment, at the bedside.