CRD summary

This review compared the effectiveness of different methods for the stabilisation of oral endotracheal tubes (ETT). From the evidence available, no one method of ETT stabilisation could be identified as more superior than another. Given the paucity of evidence and differences between the included studies, the authors' conclusions appear justified and their recommendations for further research are reasonable.

Authors' objectives

To determine which method for the stabilisation of oral endotracheal tubes (ETT) is associated with the fewest numbers of tube displacements and unplanned or accidental extubations. The secondary research aims were to determine which stabilisation method results in the least amount of skin, lip and/or oral mucosa breakdown, and to determine nurses' preferences for maintenance of the patients' oral hygiene.

Searching

MEDLINE, Current Contents, CINAHL, EMBASE and the Cochrane Library (including DARE) were searched from 1993 (or inception if later) to 2003; the search terms were reported. Further studies were identified by checking the reference lists of retrieved articles and handsearching the preceding 3 years of key critical care journals (details not reported) and critical care or anaesthesia conference proceedings. Searches in online forums, such as the Australian College of Critical Care Nurses, were also conducted to try and locate unpublished data. Owing to funding constraints, only articles published in the English language were examined.

Study selection

Assessment of study quality

The validity of the included studies was assessed using a piloted, standardised assessment tool. This assessed the following aspects of methodological quality; the method of randomisation; participant inclusion or exclusion criteria; sample size; controls for potential confounding factors; study protocol changes; the baseline comparability of the study groups; and the use of subgroup analyses according to intervention and outcome variables. Two different review groups independently assessed each study. Each review group consisted of a nurse clinician and a senior nurse researcher with experience in literature searching and critical appraisal.

Data extraction

Two reviewers independently extracted the data using a piloted, standardised extraction form. This collected patient details (e.g. age, gender, APACHE II score or medical diagnosis), intervention details (e.g. oral or nasal tube, method of stabilisation) and outcome data. The units of outcome measures were reported differently within the different studies. Where possible dichotomous outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs) and continuous outcomes (e.g. amount of ETT displacement in centimetres) were reported as weighted mean differences (WMDs) with 95% CIs.

Methods of synthesis

Results of the review

Seven studies (n=1,570) were included in the review: one randomised active control equivalence study (n=228), one non-randomised controlled study (n=36), three quasi-experimental studies (n=193), one prospective time series (n=687) and one prospective observational study (n=426).

The overall quality of the studies included in the review was poor. Only three studies provided sufficient detail to be included in the meta-analysis, but no study had sufficient power to conduct multivariate analyses and so control for confounding factors. Three studies had less than 55 participants. The non-randomised controlled study lost approximately 50% of participants to follow-up, and the reasons for drop-out were open to bias. The time series study was open to confounding because of other changes in practice during the study period. One quasi-experimental study failed to validate the questionnaire used to collect the outcome data. The most rigorously designed study (the randomised active control equivalence study) used methods not found in any other study, and thus could not be included in the meta-analysis. Other problems included changes to study protocol, lack of detail on method of randomisation and baseline comparability, patient self-selection out of intervention groups, and differing length of time in the trials.

Lip excoriation (2 studies, n=175).

Commercial devices were associated with significantly fewer cases of lip excoriation in comparison with adhesive tape (OR 0.2, 95% CI: 0.1, 0.5).

Facial trauma (details not reported).

Fewer cases of facial trauma were associated with the use of commercial devices in comparison with adhesive tape (OR 0.4, 95% CI: 0.1, 1.2), but this finding was not statistically significant.

ETT displacement (3 studies).

The degree of ETT displacement was less with commercial devices than with adhesive tape (WMD 0.6 cm, 95% CI: 0.4, 0.9), but this finding was associated with significant heterogeneity.

Authors' conclusions

From the evidence available, no one method of ETT stabilisation could be identified as being more superior than another. Further rigorously designed research is required.

CRD commentary

This review was based on a clear research question with well-defined population, study design, intervention and outcome criteria. The authors based their review on a wide search for both published and unpublished data in electronic databases and other literature sources, including conference abstracts and relevant online nursing forums. However, some relevant studies might have been missed by the inclusion of only English language articles, although the authors stated that this was necessitated by funding constraints. The authors clearly described how studies were selected for inclusion in the review, their quality assessed and the data extracted. They also took appropriate steps through the use of multiple reviewers and independent review to check the robustness of each stage of the review process, thereby reducing the risk of errors and bias.

Given the differences between the included studies in terms of their populations, intervention, study design and outcome measures, the authors were justified in limiting their meta-analyses to only those studies showing sufficient clinical homogeneity. The assessment of statistical heterogeneity also provided a further check on the robustness of the data pooling. The findings of the review appear to be supported by the data presented, and the authors are justified in recommending further research to be conducted.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research is urgently required. This should be in the form of large, multicentre, well-designed RCTs to determine the most effective method for the stabilisation of oral ETT. Future studies need to be reported in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. In particular, studies should clearly define the outcome methods and the stabilisation technique used; an accompanying assessment of cost-effectiveness would be advantageous.

Bibliographic details

Gardner A, Hughes D, Cook R, Henson R, Osborne S, Gardner G. Best practice in stabilisation of oral endotracheal tubes: a systematic review. Australian Critical Care 2005; 18(4): 158-165. [PubMed: 18038537]

Indexing Status

Subject indexing assigned by NLM

MeSH

Bandages /adverse effects /economics /standards; Benchmarking /organization & administration; Clinical Nursing Research /organization & administration; Cost-Benefit Analysis; Equipment Design; Equipment Failure; Evidence-Based Medicine /organization & administration; Facial Injuries /epidemiology /etiology; Health Services Needs and Demand; Humans; Incidence; Intensive Care /economics /methods /standards; Intubation, Intratracheal /nursing; Lip /injuries; Meta-Analysis as Topic; Outcome Assessment (Health Care); Prospective Studies; Randomized Controlled Trials as Topic; Research Design; Skin Care /economics /instrumentation /nursing; Surgical Tape /adverse effects /ethics /standards; Workload

AccessionNumber

12006005085

Database entry date

28/02/2007

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.