Impact of the introduction of an endotracheal tube attachment device on the incidence and severity of oral pressure injuries in the intensive care unit: a retrospective observational study

Pressure injuries are a leading cause of preventable harm to hospitalised patients worldwide, affecting between 1 and 11% of patients in acute-care settings [1]. Among all hospitalised patients the prevalence rate of pressure injury is highest for patients in Intensive Care Units (ICU) [2]. Globally, the incidence of pressure injuries among patients admitted to ICU ranges from 5 to 20%, with a prevalence of between 14 and 47% [3‐5]. Patients in ICU have many unique factors that make them vulnerable to the development of pressure injuries. Risk factors for pressure injury development in critically ill patients may include impaired sensation, altered level of consciousness, reduced mobility, sedation, decreased tissue perfusion, nutritional compromise, and vasoactive medications [3, 6‐8].

Medical devices are often an essential component in delivering necessary care to critically ill patients, yet are also increasingly being recognised as a potential cause of pressure injury. Medical device-related pressure injuries (MDRIs) are defined as a localised injury to the skin or underlying tissue as a result of sustained pressure from a device [9]. The majority of MDRIs occur on the head, neck and face [10], and may be caused by poor device fit, improper securement, or poor visualisation of the skin under the device making it difficult to perform skin assessment [9, 11]. A lack of practice guidelines and staffing workload and experience may also impact on the risk of a medical device related pressure injury [12]. The proportion of pressure injuries that are device-related varies in the literature from 10% to 40% [2, 6, 13]. Black et al. [9] reported that patients with a medical device were 2.4 times more likely to develop a pressure injury.

Although there is an increasing awareness of the risk of MDRIs, there are few studies that have addressed specific devices and their impact on the development of pressure injury. Two recent studies have found endotracheal tubes (ETT) and nasogastric tubes to be leading causes of MDRIs [13, 14], with intubated patients at risk of developing pressure injuries from the ETT and/or the methods or devices used to secure it [15]. ETTs are secured to prevent tube migration, and to avoid unplanned extubation. There are several methods for securing ETTs, including adhesive or cloth tapes, and endotracheal tube attachment devices (ETADs). These devices are designed specifically to hold the ETT securely in a way that facilitates regular repositioning of the ETT to prevent the development of pressure injuries caused by the tube resting on the inside of the mouth or lips for prolonged periods. These devices are therefore marketed as having the potential to reduce rates of oral pressure injuries [16]; however evidence to support these claims is limited [15, 17‐20]. Two studies have found reduced skin breakdown with commercial ETT holders when compared to adhesive tape [19, 20]. Furthermore ETT holders were shown to significantly reduce internal and external movement of endotracheal tubes [20]. A systematic review and meta-analysis found significant reduction in lip excoriation with commercial devices (p < 0.001; OR = 0.2, 95%CI = 0.1–0.5), but no significant reduction in facial trauma (p = 0.11; OR = 0.4, 95%CI = 0.1–1.2) [17]. The degree of ETT displacement was found to be less with commercial devices than with adhesive tape in the setting of significant heterogeneity of the studies included [17]. A recent study comparing sixteen ETT securement methods using anatomically correct intubation models with embedded pressure sensors found that commercial devices exerted more pressure on the face than non-commercial devices and commercial ETT holders allowed for rapid and secure movement of ETT from one side of the mouth to the other. [15].

A commercially available ETAD, the AnchorFast™ (Hollister), was introduced into clinical practice in our department in mid-2013.

This study aimed to retrospectively evaluate the impact of the introduction of the AnchorFast™ device on the incidence of oral pressure injuries in our ICU.

Medical devices are a leading cause of pressure injuries in critically ill patients [2, 6], with ETTs and nasogastric tubes accounting for the majority of these [13, 14]. Oral pressure injuries related to endotracheal intubation accounted for 22.6% of all documented pressure injuries over a 6.5-year period in our ICU.

The incidence of reported oral pressure injuries appears to have increased significantly following the introduction of the AnchorFast™ device in our unit. Overall, patients with an AnchorFast™ in place were approximately twice as likely to develop oral pressure injuries. To our knowledge, only one previous study has investigated the impact of the introduction of the AnchorFast™ device on the incidence of oral pressure injuries. This retrospective 20-month study found a decrease in incidence of oral pressure injuries following the introduction of the AnchorFast™ device, from an incidence of 1.25 injuries per 100 ventilated patients to 0.06/100 ventilated patients [22]. These findings are at odds with those of the present study. It is unclear where this discrepancy may arise from, however variations in staffing and patient mix may contribute. In particular, Zaratkiewicz and colleagues reported an average of over 300 patients per month receiving IMV [22], compared to an average of 26 patients per month in our unit during the study period. This is likely to influence staffing experience and workload, as well as the length of mechanical ventilation that patients received. No information regarding patient acuity, length of mechanical ventilation, or staffing was provided in this article to enable comparisons with the present study.

Compliance with institutional policies aimed at reducing oral pressure injuries improved significantly following the introduction of the AnchorFast™ device. Similarly, compliance was significantly better among patients that developed oral pressure injuries with their ETT secured using an AnchorFast™ device compared to patients with cloth tape during the post-AnchorFast period.

According to promotional materials, the design of the AnchorFast™ device allows nursing staff to more easily reposition the ETT. This is likely to have contributed to the improved compliance with pressure injury prevention policies observed in this study; however, this does not appear to relate to a decrease in pressure injury incidence when implemented in routine practice. The reasons for this warrant further investigation.

The location of pressure injuries to the mouth and lips varied significantly between those sustained with AnchorFast™ devices and cloth tapes in place. The locations of pressure injuries reported with each method reflect areas of pressure exerted by these devices on the underlying skin (see Fig. 1), and these findings therefore have implications for the prevention of pressure injuries using these devices. This may include adjusting the way that cloth tapes are secured to reduce pressure across the corners of the mouth, and potential modifications to the AnchorFast™ device.

The severity of oral pressure injuries did not differ between those sustained with tapes and AnchorFast™ devices, with the majority of injuries reported as being stage 2 or “partial thickness skin loss with exposed dermis” [21]. The appropriateness of using standard pressure wound staging systems for the assessment of oral pressure wounds has previously been questioned [23].

Incidence of oral pressure injuries increased significantly following the introduction of the AnchorFast™ ETT securement device. Patients with an ETT secured using an AnchorFast™ device were found to be at a significantly increased risk of developing oral pressure injuries.