Who clamps their tubs before transfering to a different vent? (CCT Transfers)

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mrhunt

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SO new to CCT truck. Studying for FP-C Exam, Reading books and all that good ****.

Mostly all the books state you need to clamp the ET Tube prior to switching to a different ventilator for contamination concerns as well as Loss of PEEP. I know Reach has actual policies in place. Our companies CCT program is new and hence frequently changing and we dont clamp our tubes prior to switching......and alot of "real world" places dont seem to either.

Im aware of the reasoning WHY you need to clamp the tube so thats not really the question.
My question is....Why ARNT we? I asked all the other staff and nobody had a good answer and just shrugged like "oh well, thats just what we do!".

is this a BOOK way of doing things that nobody does in the field? Or should you REALLY be clamping your tube in the field prior to switching vents?
 
I've seen both ways. I've seen people who switch without clamping. I've seen people who make sure to clamp before switching. Some people even carry kelly clamps on their uniform! From what I've seen, it doesn't really make a big difference on routine vent calls eg stroke, trauma. Not really sure about patients who are on the vent due to respiratory failure or ARDS where I imagine this matters more.
 
mrhunt said:
SO new to CCT truck. Studying for FP-C Exam, Reading books and all that good ****.

Mostly all the books state you need to clamp the ET Tube prior to switching to a different ventilator for contamination concerns as well as Loss of PEEP. I know Reach has actual policies in place. Our companies CCT program is new and hence frequently changing and we dont clamp our tubes prior to switching......and alot of "real world" places dont seem to either.

Im aware of the reasoning WHY you need to clamp the tube so thats not really the question.
My question is....Why ARNT we? I asked all the other staff and nobody had a good answer and just shrugged like "oh well, thats just what we do!".

is this a BOOK way of doing things that nobody does in the field? Or should you REALLY be clamping your tube in the field prior to switching vents?
Click to expand...
Switching ventilators takes maybe 3 seconds. What do you think happens during routine ET suctioning? Several times a day? And if the patient isn't fully paralyzed an attempt to cough or take a breath against a clamped tube is potentially harmful. You'd probably get your hand slapped in my ICU's if you clamped an ett. In an adult, anyway...no idea about neonatal.
 
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For your routine calls it’s probably not needed. In your patients who are ARDS on high PEEP and/or infection control it might not be a bad idea to clamp it.

When COVID first started we were clamping 100% of tubes during vent transfers. It was a turn your vent on and have it all set up, get ready to turn the facility vent on standby, wait for the inspiration, clamp the tube, turn the facility vent to standby, disconnect the circuit, connect your circuit, unclamp the tube, and then start checking your vent measurements.
 
Loss of PEEP is a routine consideration in the ICU setting. Maybe this is one of the of the many examples of why folks who lack experience caring for ICU patients in the actual ICU setting shouldn't be caring for ICU patients in the transport setting? But that's another conversation, of course.

I recall once having a very sick patient on like 25 of PEEP nearly code during the brief transfer to the transport vent from the hospital vent. After the fact, the only causal factor we could come up with was loss of PEEP (my partner at the time was a very experienced RRT). In my many years of HEMS and CCT experience, I only recall seeing this once in the transport setting. In my years of SICU, CICU, and TICU experience, it recall seeing it happen a handful of few times.

My practice now as an anesthetist (I transfer patients from vent to vent pretty frequently) is simply to minimize time off PEEP as much as is practical. But unless a patient is very PEEP dependent, it doesn't matter much at all.

I certainly don't see any reason ever to literally "clamp" an endotracheal tube just to transfer from one ventilator to another. That sounds like one of the many totally-unnecessary-yet-super-cool-looking-ultimate-tactical-look-at-me-and-the-carabiners-on-my-shoulder-straps-HEMS-only practices I've seen over the years. Maybe Scott Weingart mentioned it at one point?.

Simply making sure that the transport vent is ready so that you can transport from one circuit to another in 0.2 seconds pretty much always suffices. If you are really worried, then simply put a gloved thumb over the ETT during transfer from vent to vent.

No clamp needed, ever.
 
We have never clamped a tube on any CCT shift even during the whole pick of covid. Only seen it done once at a facility when we were transferring a patient to Cedars Sinai.
 
E tank said:
What do you think happens during routine ET suctioning? Several times a day?
Click to expand...
Exactly, PEEP goes away during suction, although some truly critical patients don't tolerate it well, but those ones are usually too unstable to transport.

Proper suction in ICU uses inline to reduce VAP risk.

That said I've never seen an ETT clamped for a vent change. I am unconvinced that it is meaningful from an infection prevention standpoint either for the patient or the staff.
 
Aprz said:
I've seen both ways. I've seen people who switch without clamping. I've seen people who make sure to clamp before switching. Some people even carry kelly clamps on their uniform! From what I've seen, it doesn't really make a big difference on routine vent calls eg stroke, trauma. Not really sure about patients who are on the vent due to respiratory failure or ARDS where I imagine this matters more.
Click to expand...
A sterile glove works well when changing circuits. Heaven forbid accidental extubation, but glove in place you at least know if they are having spontaneous breaths during the procedure. If no spontaneous breaths occurring still no harm if your quick, which most of us are by nature. Ambu to ET, no need to clamp or glove. That slows the process. Make sure your PEEP valve is working on the Ambu bag‼️ Manometer at every bedside.
 
awesome information. i appreciate all the replies guys! Definately helps a newbie like me in the critical care setting to learn!
 
In a little bit of research I’ve seen clamping isn’t even all that effective unless you use ECMO clamps. Granted this study isn’t the end all be all
www.ncbi.nlm.nih.gov

Does endo-tracheal tube clamping prevent air leaks and maintain positive end-expiratory pressure during the switching of a ventilator in a patient in an intensive care unit? A bench study

When patients with acute respiratory distress syndrome are moved out of an intensive care unit, the ventilator often requires changing. This procedure suppresses positive end expiratory pressure and promotes lung derecruitment. Clamping the endotracheal ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

I’m in the camp of it not being necessary.
 
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