Endotracheal Tube Holders and the Prone Position: A Cause for Concern–Reply

In Reply:

We appreciate the comments by Gomaa and Branson concerning their patients who developed pressure sores during prone ventilation and how it relates to the findings of our study.¹ The authors are correct that the effects of prone positioning were not evaluated in our study. Prone positioning and facial edema, although both important factors in skin integrity around the airway, were not within the scope of our study. However, data derived from our observations could be used to identify airway-securing devices that had pressure points in the supine position. The Hollister AnchorFast device had an increased reading of force on the right cheekbone area (FS1) during each of the vertical and horizontal rotation phases of our testing. Airway complications are a recognized hazard during prone ventilation.²

Unfortunately, the statement in the first paragraph of the letter that “the increase in pressure exerted by the commercially available devices, which the authors reported as not clinically important” is incorrect. In fact, in the second paragraph of the discussion section, we specifically stated that “the force exerted on the patient's face by many of the commercial securing devices may result in discomfort and formation of pressure ulcers.”¹ We discussed that although there was no outlier in all of the factors tested, specific techniques/devices may prove more beneficial in certain circumstances.

We do agree and join with Gomaa and Branson in stressing the importance of therapists being aware of and vigilant in prevention of the development of pressure ulcers not only in the prone patient, but also in all patients who have artificial airways. Assessing skin integrity of all patients with artificial airways should be part of every patient evaluation regardless of the need for mechanical ventilation or prone positioning. Gomaa and Branson's reported experiences only further stress the need for continued evaluation of airway-securing procedures with more sophisticated modeling, as well as clinical observation.

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