• Anatomy and physiology of the pulmonary system should be understood.

• Anatomy and physiology of the oral cavity and the importance of evidence-based oral hygiene procedures on a regular basis should be understood.1,18,21,27,49,54

• Endotracheal (ET) tubes are used to maintain a patent airway or to facilitate mechanical ventilation. The presence of these artificial airways, especially ET tubes, prevents effective coughing and secretion removal, necessitating periodic removal of pulmonary secretions with suctioning.

• Oral care given every 2 to 4 hours appears to provide a greater improvement in oral health. If oral care is not provided for 4 to 6 hours, previous benefits are thought to be lost.¹⁰

• Suctioning of airways should be performed only for clinical indications and not as a routine fixed-schedule treatment (see Procedure 12). In acute care situations, suctioning is performed as a sterile procedure to prevent healthcare-acquired pneumonia.

• Adequate systemic hydration and supplemental humidification of inspired gases assist in thinning secretions for easier aspiration from airways.20,36,37,51

• Appropriate cuff care (see Procedure 13) helps prevent major pulmonary aspirations, prepares for tracheal extubation, decreases the risk of inadvertent extubation, provides a patent airway for ventilation and removal of secretions, and decreases the risk of iatrogenic infections.^{5,15,29,37,51}

• Constant pressure from the ET tube on the mouth or nose can cause skin breakdown.

• If the patient is anxious or uncooperative, use of two caregivers for retaping or repositioning the endotracheal tube helps prevent accidental dislodgment of the tube.

• The incidence of ventilator-associated pneumonia (VAP) is increased in patients intubated for longer than 24 hours.36,37,51

• Nasotracheal intubation should be avoided because it increases the risk of VAP.37,51

• VAP is a risk factor for endotracheal intubation.

• Goggles or glasses and mask

• Bite-block or oral airway if needed

• Adhesive or twill tape; commercial endotracheal tube holder (design must ensure ability to provide oral care and suctioning)

• 2 × 2 Gauze or cotton swab for cleaning around the nares

• Normal saline solution

• Soft pediatric/adult toothbrush or suction toothbrush

• Toothettes/oral swab/oral suction swab

• Oral cleansing solution (e.g., 1.5% H₂O2,3,18,31,44,47 chlorhexidine,^{3,6,9,16,22,23,26,34,52} cetylpyridinium chloride [CPC],^3,30,43,50 toothpaste^10,24,40)

• Closed-suction setup with a catheter of appropriate size (Table 4-1)

• Sterile saline solution lavage containers for cleansing the closed suction system after use (5 to 10 mL)

• Suction catheter for oral and nasal suctioning (single-use Yankauer, covered Yankauer, disposable oral saliva ejector)

• Two sources of suction or a bifurcated connection device attached to a single suction source

• Connecting tube (4 to 6 ft)

• Nonsterile gloves

• Stethoscope

• Explain the procedure to the patient and family, including the purpose of ET tube care and the importance of comprehensive oral care in prevention of infection.¹ Rationale: This step identifies patient and family knowledge deficits concerning patient condition, procedure, expected benefits, and potential risks and allows time for questions to clarify information and voice concerns. Explanations decrease patient anxiety and enhance cooperation.

• If indicated, explain the patient’s role in assisting with ET tube care. Rationale: Eliciting the patient’s cooperation assists with care.

• Explain that the patient will be unable to speak while the ET tube is in place but that other means of communication will be provided. Rationale: This information enhances patient and family understanding and decreases anxiety.

• Explain that the patient’s hands may be immobilized to prevent accidental dislodgment of the tube. Rationale: This information enhances patient and family understanding and decreases anxiety.