Securing the endotracheal tube (ETT) following intubation is a routine procedure during general anesthesia with tracheal intubation. Proper fixation of the ETT is crucial for effective ventilation during general anesthesia while minimizing potential complications due to ETT displacement. Displacement of the ETT can result in endobronchial intubation and accidental extubation [1]. If unrecognized, endobronchial intubation can lead to hypoxemia caused by atelectasis formation in the unventilated lung, and hyperinflation and barotrauma with the development of pneumothorax of the intubated lung [2]. Accidental extubation can lead to serious complications, such as laryngeal injury, vocal cord injury, aspiration, respiratory arrest, arrhythmias, hypoxemia, hypotension, cardiac arrest, anoxic brain injury, or even death [3] - [8].

Although many methods of securing ETT, including adhesive tapes, sutures, silk ties, commercial ETT holders, umbilical cord clamps, or a combination of these techniques have been used to reduce the displacement of ETT, the best method of securing ETT remains a controversial issue [9] - [14]. Additionally, anesthesia textbooks do not describe how to fix ETT in detail. The case reports of accidental extubation during general anesthesia can still be found in recent years [7] [15] [16] [17] [18] [19], however, the cases of ETT displacement and its consequences might be underestimated in the literature.

Therefore, the objective of the surveys was to investigate how many anesthesiologists had ever experienced the ETT displacement and its consequences during anesthesia, and the surveys were performed in 2014 and 2020 respectively, in China. The results for 2014 with those for 2020 were compared to investigate the advance in ETT fixation methods. This survey will provide preliminary information on ETT fixation methods, ETT displacement frequency and the possible factors to cause ETT displacement.

The surveys indicate that a majority of anesthesiologists in China experienced ETT displacement during general anesthesia in 2014 and 2020. A minority of anesthesiologists even experienced cardiac arrest and death of patients due to ETT displacement. A majority of the respondents secured ETT in the shape of the letter X with adhesive tape. A majority of respondents considered the influence of surgical site, position, and age on securing the ETT, after which most of them would reinforce the ETT with other materials.

ETT displacement, especially accidental extubation, is a potentially life-threat-ening complication that can occur following intubation. However, literature on the incidence of accidental extubation and ETT displacement in surgical patients with general anesthesia remains limited. In our survey, among all participants, 65.6% had experienced ETT displacement, and 4.3% had experienced serious complications such as hypoxemia, cardiac arrest, or death due to ETT displacement. Although the incidence of ETT displacement experienced by anesthesiologists decreased by 9.7% in 2020 compared with that in 2014, it was still as high as 62.4%. A previous study has shown that 12% of the airway cases in the anesthesia closed claims analysis were caused by premature extubation [20]. In clinical anesthesia, preventing the ETT displacement and reducing the complications related to ETT displacement should be a priority.

There are many risk factors for ETT displacement in general anesthesia during surgery. Previous studies have shown that head and neck movement could lead to unexpected tube displacement [21] [22] [23] and patients who underwent a supine-to-prone position change were more likely to experience ETT displacement [24]. Additionally, children younger than 2 years presented greater unplanned extubation rates than children over 2 years [25]. Another study found that unplanned extubations were more common in children who were younger than 5 years compared with older children [26]. In our survey, lower profession title, without placing the bite block, without the consideration of surgical site or position and without the consideration of age were the risk factors of ETT displacement. So a majority of respondents had considered the influence of surgical site, position, and age on securing ETT. As such, a majority of respondents indicated that they reinforced the ETT with adhesive tape, transparent film dressing, or other materials.

Previous studies on the optimum fixation material and method have yielded contradictory results [9] [12] [13] [27]. Our survey found that there were differences in fixation methods between 2014 and 2020, the fixation materials did not change significantly. Adhesive tape was the most commonly used fixation material in clinical practice and only a minority of respondents routinely used other materials, including transparent film dressing, bandages, sutures, ETT-holders. The proportion of respondents who stated that improperly fixing ETT was the primary cause of ETT displacement was higher than that who indicated that poor quality of fixation materials led to ETT displacement (37.3% and 2.8%, respectively). In the opinion of respondents, the fixation methods were more critical than the fixation materials for preventing ETT displacement. Our survey showed a majority of respondents secured ETT with adhesive tape in the shape of the letter X. In addition, the fixation method in the shape of letter H, the fixation method in the shape of the letter Y, and other methods with adhesive tape are often used in clinical practice [28] [29]. The optimum fixation method needs to be explored.

So far, there are few surveys to investigate the ETT displacement experienced by anesthesiologists and consequences during general anesthesia. Among the respondents, 63.1% had been practicing for 6 or more years, and 60.1% had a professional title of attending physician or higher. All of the respondents were active in anesthesia clinical work, and 83% of the respondents performed more than 25 cases of ETT per month, indicating a high level of reliability of the questionnaire responses. Meanwhile, all the questionnaires were filled out anonymously, so the respondents did not have any relevant concerns. These measures ensured the authenticity and reliability of this survey.

The major limitation of this study was that the cases and the consequences of ETT displacement were reported solely by the memory of the respondent, and there might be some discrepancy between the respondents’ memory and the clinic records. Additionally, except for work experience and professional titles, other factors such as gender or educational background, might also affect the fixation of ETT, which we hope to address in our future work. Moreover, the differences in the survey methods may have led to differences in the characteristics of respondents. Compared with the online survey, a higher proportion of face-to-face respondents came from grade 3 class A hospitals and were chief physicians, which may have led to differences in the incidence of ETT displacement experienced by respondents between 2014 and 2020.

In conclusion, a majority of anesthesiologists experienced ETT displacement, which may result in serious complications during general anesthesia. Therefore, management of the ETT should be paid more attention during the operation.

We thank Hongbin Feng, Zijia Li, Zhinan Zheng, Shanmei Wu, Nanrong Zhang and all other colleagues in our department for their assistance in the collection of questionnaires. We thank the respondents for their participation in the investigation.

Sanqing Jin designed the study and supervised the whole process of the study and revised the manuscript. Dongxue Li and Tongfeng Luo collected and analyzed the data, and wrote the manuscript. Chuling Liu and Xi Hong checked and analyzed the data. All authors read and approved the final version.

The authors declare no conflicts of interest regarding the publication of this paper.

Li, D.X., Luo, T.F., Liu, C.L., Hong, X. and Jin, S.Q. (2021) Should We Pay More Attention to Endotracheal Tube Fixation during Anesthesia—Surveys from Chinese Anesthesiologists for Endotracheal Tube Fixation and Endotracheal Tube Displacement in 2014 and 2020. Open Journal of Anesthesiology, 11, 243-258. https://doi.org/10.4236/ojanes.2021.118024

Questionnaire of ETT displacement

Do you agree to participate?

Yes No

Your basic information

1) Your hospital

Province: City:

2) Your hospital is:

a) General hospital b) Specialized hospital

3) The grade of your hospital is:

a) Grade 3 class A b) Grade 3 class B c) Grade 2 class A

d) Grade 2 class B e) Other grades

4) Your work experience: ___ years

5) Your professional title:

a) Chief physician b) Association chief physician

c) Attending physician d) Resident physician

6) The cases of endotracheal intubation you performed per month in your memory:____

ETT fixation status in the clinic

7) Whether you fixed the ETT by yourself after the endotracheal intubation?

a) Fixed the ETT by yourself

b) Fixed the ETT by others under your supervision

c) Fixed the ETT by others

8) The material for fixing the ETT:

a) Silk medical adhesive tape b) Plastic medical adhesive tape

c) Transparent film dressing d) Baggage e) Others (ETT-holder)

9) Whether you usually place a bite block after endotracheal intubation?

a) Yes b) No

10) The method for fixing the ETT with adhesive tape:

a) Fixed the ETT in the shape of the letter X*

b) Fixed the ETT in other methods

*The shape of the letter X: using two pieces of adhesive tapes of appropriate length and width, where one piece of tape was attached to one side of the cheek, wrapped around the tube two circles, and subsequently cross-fixed on the same side of the cheek, and the other piece of tape was attached to the other side of the cheek, wrapped around the tube two circles, and then cross-fixed on the same side.

11) When placing a bite block, the method that you fixed the ETT was:

a) Fixed the bite block and ETT together

b) First fixed the ETT and then fixed the bite block with ETT

c) Fixed the ETT and bite block completely separately

d) Only fixed the ETT, not the bite block

The respondents who have experienced ETT displacement and the serious consequences

12) Did you experience the ETT displacement during your clinical anesthesia

a) Yes b) No

13) How many cases of ETT displacement you have experienced: _____

14) Did you experience serious consequences caused by the ETT displacement

a) Yes b) No

15) The serious consequence caused by the ETT displacement you have experienced:

a) Death b) Cardiac arrest c) Hypoxemia d) Atelectasis

e) Others

The factors influencing anesthesiologists to determine the method of ETT fixation.

16) Did you consider the influence of the surgical site and position on fixing the ETT?

a) Yes b) No

17) The material for fixing the ETT in patients who underwent head and neck surgery or in the prone position

a) The same as the material for fixing general ETT.

b) Reinforce with adhesive tape

c) Reinforce with a transparent film dressing.

d) Reinforce with other materials

18) Did you consider the influence of the age of the patient on fixing the ETT?

a) Yes b) No

19) The material for fixing the ETT in pediatric

a) The same as the material for fixing general ETT.

b) Reinforce with adhesive tape.

c) Reinforce with a transparent film dressing.

d) Reinforce with other materials

20) In your opinion, the primary cause of ETT displacement in patients in the supine position with except head and neck surgery:

a) Improperly fixed

b) Poor quality of fixation materials

c) A change in position

d) Staff mistakes

e) Excessive oral secretion