The Insecure Airway: A Comparison of Knots and Commercial Devices for Securing Endotracheal Tubes

BACKGROUND: ETTs are commonly secured using adhesive tape, cloth tape, or commercial devices. Adhesive and cloth tape have been reported equally effective, but there has been no experimental comparison of cloth tape tied with different knots. Movement of an ETT by 3cm may be life-threatening. OBJECTIVES: To compare rates of failure of the following methods: cloth tape tied with 3 different hitches (Lark's Head (LH), Clove (CH), and Magnus (MH)); nasal cannula tubing tied with CH (NC); and 6 commercial devices (Comfit (Ackrad), Stabiltube (B & B Medical), Tube Restraint (ErgoMed), ETAD (Hollister), Thomas ST (STI Medical) and Dale ETT Holder). METHODS: A 17cm diameter PVC tube with 14mm "mouth" hole in the side served as a mannequin. Cloth tape was 1.25cm synthetic twill. ETTs were secured with cloth tape, NC or devices and subjected to repeated jerks of 2.5, 5 or 10 lbs. 3-10 tests were performed for each knot/device. All knots/devices were wet with saline. Failure was movement >/=3cm. RESULTS: 3 types of failure were identified: slip, stretch and breakage. Cloth tape never broke: all failures were stretch or slip. Stretch failure was similar for all knots, averaging 2.8cm at 5lb x 6 jerks. Comparing hitches, MH (2.8cm) and CH (2.44cm) produced less slippage than the commonly recommended LH (6.21cm). NC produced almost no slip (1cm) but unacceptable stretch occurred (3.25cm at 5lb x 6 jerks). Among devices, all devices failed consistently either at 2.5lb x 12 jerks or 5lb x 6 jerks-with the sole exception of the Dale, which consistently passed both tests (p < 0.01). All devices, including the Dale, failed at loads >/=10lb. CONCLUSIONS: CH and MH hitches are superior to the LH for securing ETTs. NC stretches too much to be recommended. Cloth tape breaks less easily than all commercial devices tested. Development of a synthetic cloth tape with improved grip and reduced stretch would markedly reduce failure. Among devices, for dynamic loads