Tolerance of the endotracheal tube: a systematic literature review

22.1

1.15

Nydahl, Nursing Research

Project of the German Early Mobilization Network Nydahl P, Hermes C, Dubb R, Kaltwasser A, Schuchhardt D (2015). Toleranz des endotrachealen Tubus bei beatmeten Intensivpatienten. Med Klin Intensivmed Notfmed 110(1):68-76.

Background & problem

Nydahl, Nursing Research

Background Clinicians have concerns about patient‘s tolerance of ETT, with consequences for more sedation, fixation and less mobilization1,2,3

Definition In favor of a higher value (health) a lesser competing value (ETT) is accepted. It is the "will to allow something“4

Question What factors have got an impact on patient‘s tolerance of an ETT?

1 Aitken 2011, 2 Grossbach 2011, 3 Needham 2011, 4 Moore 2011

Method

Nydahl, Nursing Research

•  Data bases: Pubmed, CINAHL, hand search

•  Time frame: till Aug. 2014 •  Terms: patient experience, ventilator,

tube, endotracheal tube, tolerance, acceptance, compliance, comfort, discomfort

•  Design: quantiative & qualitative studies •  Excluded: ETT during operation & short-

term procedures, children, unclear ETT vs trach.

Results

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•  8 quantitative studies5-12, incl. 2 RCT8,12

•  4 qualitative studies13-16

•  2 mixed design17,18

•  High risk of bias: not able to remember, suggestions instead of questions •  ETT vs trach9,12: no difference in tolerance or outcome

•  Is tolerance measurable by choking, swallowing, breathing, removal?

5 Rotondi 2002, 6 Machata 2007, 7 Samuelson 2007, 8 Samuelson 2008, 9 Saur 2009, 10 Samuelson 2010, 11 Khalaila 2011, 12 Trouillet 2011, 13 Johnson 2006, 14 Schou 2008, 15 Karlsson 2012, 16 Clukey 2014, 17 Grap 2002, 18 Van der Leur 2004

Results

Nydahl, Nursing Research

•  8 quantitative studies5-12, incl. 2 RCT8,12

•  4 qualitative studies13-16

•  2 mixed design17,18

•  High risk of bias: not able to remember, suggestions instead of questions •  ETT vs trach8,12: no difference in tolerance or outcome

•  Is tolerance a measurable by choking, swallowing, breathing, removal?

5 Rotondi 2002, 6 Machata 2007, 7 Samuelson 2007, 8 Samuelson 2008, 9 Saur 2009, 10 Samuelson 2010, 11 Khalaila 2011, 12 Trouillet 2011, 13 Johnson 2006, 14 Schou 2008, 15 Karlsson 2012, 16 Clukey 2014, 17 Grap 2002, 18 Van der Leur 2004

Incidence of unplanned removals per 1,000 days Central venous lines 12.4 ETT 24.7 Arterial lines 46.5 Stomach tubes 73.9 Carrion 2000

Related factors

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Decrease tolerance

Endotracheal suctioning

Getting insufficient air

Being speechless

Pain

Anxiety Dependence

Constriction

Swallowing

Fixation of ETT

Movements of ETT

Related factors

Nydahl, Nursing Research

Increase tolerance Able to survive

Able to breath

Being patient

Needs were considered

Depth of sedation Drugs

Distraction

Family presence

Nurses

Mobilization and

rehabilitation

Related factors

Nydahl, Nursing Research

Decrease tolerance

Endotracheal suctioning

Getting insufficient air

Being speechless

Pain

Anxiety Dependence

Constriction

Swallowing

Fixation of ETT

Movements of ETT

Competence, analgesia

Adaption ventilator

Tablets, comm. aids

Screening, analgesia

Information, family, drugs

Empower-ment

Control cuff

Control cuff, drugs

Replace fixation, diff

type

Re-move ETT, fixation

Delirium screening &

management

ETT tolerance

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•  Is a complexe phaenomenon •  Requieres specific observation and evaluation •  Nurses may have a lower ETT tolerance than patients (high value:

well-being & comfort) •  Deeper sedation seems to be an insufficiant strategy, but may be

required due to staff problems (competence, workforce shortages) •  Most useful strategies:

•  Empowerment of the patient‘s understanding •  Ask patient what strategy may be most useful •  Family presence •  Early mobilization