Endotracheal tube care and VAP prevention: securing, cuff pressure, tube depth, oral care, head of bed and unplanned extubation
- Procedure
Each shift the nurse checks tube depth, fixation, cuff pressure and skin, keeps the head of the bed raised and brushes the teeth to prevent pneumonia.
What it is
An endotracheal tube bypasses the airway's defences. Secretions pool above the cuff and can seep into the lungs, causing ventilator-associated pneumonia (VAP). Nursing care keeps the tube at the right depth and well secured, the cuff sealed without injuring the trachea, the mouth clean and the patient positioned to reduce aspiration. It also prevents unplanned extubation, which is most often the patient pulling the tube out because of agitation, delirium or too little sedation. The general infection bundles are on the HAI bundles page, and suctioning technique on the suctioning page.
Indications
- Every patient with an oral or nasal endotracheal tube on mechanical ventilation.
- After intubation, transport, repositioning or a prone turn.
- Any sign of a cuff leak, tube movement or a loose fixation.
- Agitation, delirium or a sedation break, when the risk of self-extubation rises.
Contraindications and precautions
- Keep the tube held at its marked depth while the fixation is changed, as the institutional protocol describes.
- Too much cuff pressure injures the trachea (stenosis, fistula to the oesophagus); too little lets secretions reach the lungs.
- Suction the mouth before deflating or moving the cuff so pooled secretions do not fall into the trachea.
- Avoid unnecessary disconnections of the circuit: they lose PEEP and collapse lung units.
- Do not use routine chlorhexidine for mouth care.
Equipment
- Cuff pressure manometer.
- Tube holder or tape as the protocol says, and skin protection for lips and face.
- Toothbrush, oral care supplies and oral suction.
- Closed in-line suction catheter and, if the tube has one, the subglottic drainage line.
- Bite block if the patient bites the tube.
Step by step (and why)
- Perform hand hygiene and wear gloves — the tube and the mouth are a way in for germs.
- Check the depth mark at the lips or teeth against the record — a deeper tube can enter one mainstem bronchus.
- Measure cuff pressure with a manometer and keep it in the range the protocol sets, often 20–30 cmH2O — too high injures, too low leaks.
- Inspect the fixation and the skin of the lips, mouth corners and face; reposition the tube as the protocol allows — devices cause pressure injuries.
- Keep the head of the bed at 30–45° during care unless contraindicated — it reduces aspiration of secretions.
- Brush teeth, gums and tongue daily and suction the mouth — toothbrushing lowers VAP rates.
- Suction above the cuff (subglottic port if present) before moving or deflating it — pooled secretions would fall into the lungs.
- Drain condensate in the circuit away from the patient — it is contaminated and must not run toward the tube.
- Assess agitation, pain, sedation and delirium every shift, and watch closely during sedation breaks — agitation drives self-extubation.
- Record depth, cuff pressure, skin, oral care and secretions — the next shift can see changes early.
Complications
- Ventilator-associated pneumonia.
- Unplanned extubation (self-extubation or accidental) and tube displacement.
- Tube blocked by secretions or bitten and kinked.
- Tracheal injury from high cuff pressure: stenosis or tracheo-oesophageal fistula.
- Pressure injury of the lips, mouth corners and face.
- Microaspiration from a cuff with too little pressure.
Next step: when to call for help
- Tube out or displaced, a large leak or no chest rise: call for help at once and ventilate with the bag as the protocol says.
- Cuff pressure that will not stay in range, or a deflated pilot balloon: report it; the cuff may be damaged.
- New fever, purulent secretions or a rising oxygen need: report them; VAP is possible.
- Skin breakdown on the lips or face: report and record it.
Test yourself
Think of the answer, then tap the question to see it.
At what angle should the head of the bed be for a ventilated patient, if there is no contraindication?
Between 30 and 45 degrees, to reduce aspiration of secretions and the risk of ventilator-associated pneumonia.
How should cuff pressure be checked?
With a cuff manometer, keeping the range the protocol sets (often 20–30 cmH2O). Squeezing the pilot balloon is unreliable and tends to overinflate.
What does SHEA 2022 recommend for mouth care in ventilated adults?
Daily oral care with toothbrushing, without routine chlorhexidine, because chlorhexidine did not clearly lower VAP and may cause harm.
What is the most common type of unplanned extubation, and what drives it?
Self-extubation, driven by agitation, delirium and inadequate sedation; poor fixation and a tube placed too high favour accidental extubation.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update (Infection Control & Hospital Epidemiology, SHEA/IDSA/APIC (open access, PMC), 2022); Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), respiratory care pocket card (World Health Organization, 2022); Knowledge and practice of tracheal tube cuff pressure monitoring: a multicenter survey of anaesthesia and critical care providers in a developing country (Patient Safety in Surgery (open access, PMC), 2022); Characteristics and outcomes of unplanned extubation in adult ICU: two-year retrospective observational cohort study (The Journal of Critical Care Medicine (open access, PMC), 2026).
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Representative model, for educational purposes only.