Perioral Ulcer Secondary to Endotracheal Tube Fixation: An Untoward Complication

To the Editor,

Endotracheal intubation and prolonged mechanical ventilation are frequently encountered in the critical care units. Proper fixation of the endotracheal tube (ETT) is warranted to prevent inadvertent displacement of the tube, which can lead to disruptions in mechanical ventilation and result in airway-related complications. There are various devices and techniques for securing an ETT after intubation. The American Heart Association’s 2005 Advanced Cardiac Life Support guidelines recommended using either an adhesive tape or an ETT holder to secure the ETT.¹ The commercially available ETT holders are less frequently used in developing countries due to cost restraints, and hence fixation using adhesive tapes is frequently done, especially in resource-limited settings.² We report an untoward complication of a peri-oral pressure ulcer associated with the usage of tight adhesive tapes for fixation of the ETT. A 45-year-old male with an alleged history of a road traffic accident presented to the emergency department with a history of loss of consciousness and altered sensorium. The airway was secured with an ETT, and mechanical ventilation was initiated. He was diagnosed with a right subdural haematoma (SDH) and inferior articular facet fracture of C6 along with anterolisthesis of C6 over C7 vertebra. Decompressive craniectomy was done for SDH, followed by 540° fixation of the cervical spine injury. In the postoperative period, the patient required prolonged mechanical ventilatory support for more than 10 days and hence was planned for tracheostomy. During tracheostomy, when the adhesive tape fixation of the ETT was removed, an ulcer was found at the angle of the mouth on the right side where the ETT was fixed [Figure 1]. The ulcer was likely due to the pressure exerted by the tight adhesive tapes, leading to skin necrosis. Consultation from the plastic surgery department was obtained, and the ulcer was conservatively managed.

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Figure 1:

Ulcer at the angle of the mouth where the endotracheal tube was fixed with Adhesive tape.

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The most common complication associated with improper ETT fixation is displacement of the tube and accidental extubation. It can also increase the incidence of airway-related complications such as aspiration and hypoxia. This can be detrimental to patients, especially in high-risk settings such as pre-hospital trauma care, critical care units, casualty, and during cardiac arrest.³ ETT holders are frequently being used when available, for securing the ETT in place. These devices have many advantages over the conventional fixation techniques using adhesive tapes. They are associated with less displacement of the ETT and require less time for fixation compared to the conventional techniques.⁴ Tight adhesive taping and other factors, such as the dragging force of the breathing circuit on the ETT when not properly placed, can lead to the exertion of excessive pressure on the skin surface, which can negatively impact the microcirculation and lead to pressure necrosis over a prolonged duration. In the above case, prolonged duration of surgery in the prone position could have been an additional risk factor for the development of a pressure ulcer. These multiple factors can result in the development of peri-oral ulcers at the site of ETT fixation. The incidence of pressure ulcers associated with ETTs ranges from 7% to 45%.⁵ The ulcers can be associated with secondary complications such as bleeding, especially if the patient is on anticoagulants, can increase the risk of infections and ventilator-associated pneumonia by aiding in the colonisation of microbes, and healing by stricture can lead to decreased mouth opening and difficulty in airway management. It can also be indicative of poor quality of care in the intensive care unit. Hence, proper safety measures should be followed while securing an ETT. Precautionary steps that can be taken to prevent peri-oral ulcers associated with ETT fixation include using ETT holders when available and placing a small piece of sponge or gauze between the skin surface and ETT before fixation. This will prevent direct contact of the skin surface and ETT and can decrease the pressure exerted on the skin.⁶

Regular visual inspections of the site of fixation should be done. Although there are no recommendations or guidelines on how frequently the adhesive taping should be replaced, it is not unreasonable to change the taping at regular intervals when a prolonged duration of mechanical ventilation is expected. This can help in visual inspection as well as release the continuous pressure exerted on the skin. However, this should be done in the presence of an anaesthesiologist or intensivist to prevent inadvertent extubation. If signs of skin necrosis, such as colour change and superficial ulcers, are present, then an alternate site or technique of tube fixation should be done.