# Preventing unplanned extubations: A test bench simulation comparing endotracheal tube securing techniques in acute care settings

Jérôme E Dauvergne, Yvan Derouin, Frédéric Marie, Olivier Bazin, Bertrand

Rozec, Eric Courteille, Karim Lakhal, Ronan Le Breton

► To cite this version:

Jérôme E Dauvergne, Yvan Derouin, Frédéric Marie, Olivier Bazin, Bertrand Rozec, et al. Preventing unplanned extubations: A test bench simulation comparing endotracheal tube securing techniques in acute care settings. Journal of Critical Care, 2025, 91, pp.155332. 10.1016/j.jcrc.2025.155332. hal-05375941

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# Preventing unplanned extubations: A test bench simulation comparing endotracheal tube securing techniques in acute care settings

Jérôme E. Dauvergne, RN<sup>a,b,*</sup>, Yvan Derouin, CRNA, PhD<sup>c,d</sup>, Frédéric Marie, ING<sup>e</sup>, Olivier Bazin, CRNA<sup>c,f</sup>, Bertrand Rozec, MD, PhD<sup>a,b</sup>, Eric Courteille, PhD<sup>e</sup>, Karim Lakhal, MD<sup>a</sup>, Ronan Le Breton, PhD<sup>e</sup>

## ARTICLE INFO

### Keywords:

Airway extubation (MeSH)

Endotracheal extubation (MeSH)

Endotracheal tube

Extubation force

Securing technique

Unplanned extubation

## ABSTRACT

**Background:** Effective securing of the endotracheal tube (ETT) after inserting is essential to prevent unplanned extubation (UE). This study compared six ETT securing techniques and a no-device control in resisting to simulated UE, assessing performance across different traction speeds (slow and fast) and planes (frontal and sagittal).

**Method:** A mechanically ventilated mannequin was used. Extubation, defined as a sudden loss of airway pressure, was induced using a tensile testing machine. The required force to cause extubation (force<sub>extubation</sub>) was recorded. For each combination of securing technique, traction speed and traction plane, five measurements of force-<sub>extubation</sub> were collected. Techniques included three cord-based, two elastic adhesive tape-based, one commercial device (AnchorFast<sup>TM</sup>, Hollister), and a control with no securing method.

**Results:** In the sagittal plane, AnchorFast<sup>TM</sup> required significantly higher force<sub>extubation</sub> (median 75 N [IQR: 52–86]) compared to adhesive tape methods (short: 28 N [19–34], *p* < 0.001; long: 34 N [24–45], *p* = 0.026). Cord-based techniques performed similarly to the AnchorFast<sup>TM</sup>. The control setup (i.e., without any securing device) and the elastic adhesive tape showed comparable force<sub>extubation</sub> levels which were also significantly lower than that of a single cord with a knot. In the frontal plane, force<sub>extubation</sub> was higher than in the sagittal plane (115 N [89;148] and 44 N [26;57], respectively, *p* < 0.001), and no significant differences were observed between techniques.

**Conclusion:** ETT securing techniques using elastic adhesive tape were less effective at preventing simulated UE than either the AnchorFast<sup>TM</sup> device or a single cord with a knot.

## 1. Introduction

Endotracheal intubation is used for respiratory support in acute care settings [1]. The endotracheal tube (ETT) must be secured to prevent mobilization and ensure proper ventilation. Selective bronchial intubation exposes to complications associated with unipulmonary ventilation. On the other hand, unplanned extubation (UE) – either self-

extubation or accidental extubation – can also have negative consequences, often life-threatening [2,3]. UE is not rare, with an incidence of approximately 1 per 100 days of mechanical ventilation, and nearly 10 % of all extubations occurring accidentally [4,5]. Besides self-extubation, there are numerous reasons why an ETT could be accidentally dislodged, ranging from routine mobilization of the patient for daily care to intra-hospital transfers.

<footnote><sup>a</sup> Nantes Université, CHU Nantes, INSERM, service d'anesthésie-réanimation, hopital Laënnec, CIC 1413, Nantes F-44000, France</footnote>

<footnote><sup>b</sup> Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes F-44000, France</footnote>

<footnote><sup>c</sup> Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Nantes F-44000, France</footnote>

<footnote><sup>d</sup> Nantes Université, Université de Tours, CHU Nantes, INSERM, Methods in Patients-centered outcomes and Health Research, Sphere, Nantes F-44000, France</footnote>

<footnote><sup>e</sup> Université de Rennes, INSA Rennes, LGCGM, Rennes F-35000, France</footnote>

<footnote><sup>f</sup> Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SIMU) de Nantes, Nantes F-44000, France</footnote>

<footnote>* Corresponding author at: Service d'Anesthésie-Réanimation, Hopital Laënnec, CHU de NANTES, NANTES cedex 1 F-44093, France.</footnote>

<footnote>E-mail addresses: jerome.dauvergne@chu-nantes.fr (J.E. Dauvergne), yvan.derouin@chu-nantes.fr (Y. Derouin), frederic.marie@insa-rennes.fr (F. Marie), olivier.bazin@chu-nantes.fr (O. Bazin), bertrand.rozec@chu-nantes.fr (B. Rozec), eric.courteille@insa-rennes.fr (E. Courteille), ronan.le-breton@insa-rennes.fr (R. Le Breton).</footnote>
To date, there are no formal recommendations on how to secure the ETT, and various practices are observed [6]. Several securing techniques are proposed, from the simplest, made from elastic adhesive tape or cord, to most sophisticated ones. Elastic adhesive tape or cord have the advantage of being adjustable and adaptable to any morphology. Nevertheless, they expose to skin injuries related to the adhesive compound or to cord-induced friction [7]. They are not reusable and need to be replaced daily. More advanced techniques may be easier to use and include built-in features to improve patient comfort and reduce the risk of pressure injuries. However, they are bulkier and less adaptable to individual anatomy features or facial injuries. Furthermore, an elastic adhesive tape costs only a few cents, whereas an advanced commercial device costs €10–20 [7].

A few bench studies have compared different securing techniques. They yielded conflicting results [8,9]. The techniques were subjected to tensile tests simulating UE. Nevertheless, the methods used were not strictly standardized. UE was induced by manual traction, constant weight release, or by adding weight to an ETT. Additionally, simulated unplanned extubation (hereafter referred to as UE<sub>simulation</sub>) was generally defined either as a modification of the securing technique (breakage or detachment) [10], or as a displacement of the ETT with an arbitrarily chosen magnitude [10-14]. However, this magnitude of displacement-based definition lacks clinical relevance, as such arbitrary thresholds do not reflect the variability or complexity of real-world practice.

We herein compared several ETT securing techniques in their ability to resist a tensile stress simulating UE on a mannequin. We used an

innovative and rigorous UE<sub>simulation</sub> method, designed to approximate real-life conditions as closely and reliably as possible, while acknowledging the inherent limitations of any simulated environment. Different speeds and planes of traction were tested.

## 2. Method

### 2.1. Ethic statement

This prospective study was conducted in a laboratory environment with measurements only performed on a mannequin. All measurements were performed in June 2023 under controlled laboratory conditions. Beforehand, this study was approved by the Ethic committee for anesthesia and critical care research of the French Society of Anesthesia and Critical Care on November 11, 2023 (IRB 00010254-2022-114). This manuscript complies with Simulation-Based Research Extensions of the STROBE Statement guideline [15].

### 2.2. ETT securing techniques

We tested the cord both with or without a protective plastic sheath, elastic adhesive tapes, and an advanced commercial device (Anchor-Fast™ [Hollister®, Libertyville, IL, USA]). Additionally, different fastening techniques were investigated: a single cord into a sheath, secured either by a knot or by elastic adhesive tape, and two types of elastic adhesive tapes, both 1.5 cm wide: short (35 cm) and long (60 cm).

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** ETT Securing techniques. Presentation of the 6 securing techniques assessed with a diagram explaining the securing technique set-up. The control model, without any securing technique, has not been illustrated. The dotted blue line shows the position of the ETT. Abbreviations: ETT: endotracheal tube. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)</figcaption></figure>
Alongside the 6 different securing techniques, control measurements were also performed without any securing technique (Fig. 1).

The material typically utilized in the intensive care unit and the operating room was employed to secure the ETTs: UrgoCrepe™ 2.5 m × 3 cm (Urgo Healthcare, Dijon, France) for elastic adhesive tape (composed of a cellulose backing coated with an adhesive elastomer and synthetic resin mixture) and Fixsond™ (Cair LGL, Lissieu, France) for cord. The latter was inserted into a plastic sheath that could be removed according to the fastening method evaluated. None of the expiration dates have been reached at the time of measurements.

## 2.3. ETT

We used a Portex® tracheal tube (low pressure/high volume cuff), 7.5 mm internal diameter (ICU Medical, San Clemente, CA, USA). The ETT was inserted by direct laryngoscopy with a n°3 Macintosh blade, without lubrication, by an experienced practitioner (YD). The cuff was placed beyond the vocal cords via visual control, up to the 22 cm graduated mark measured at the level of mannequin's front teeth. The ETT cuff was pressurized at 30 cm H₂O. The tube's outer tip was sealed to ensure airtightness and allow gripping during tensile testing (Supplemental Fig. 1). Then, the securing technique was applied. The ETT was replaced every 5 extubations.

As a preliminary study, tensile stress tests were carried out on an ETT alone to assess its behavior when subjected to traction under 2 speed conditions, each repeated twice. The ETT-only tests were stopped when the ETT slipped out of one of the jaws. A certain deformability was demonstrated (Supplemental Fig. 2).

## 2.4. UE<sub>simulation</sub> procedure

UE<sub>simulation</sub> refers to a simulated scenario replicating the displacement of clinical UE, conducted without patient involvement. As displayed in Fig. 2, the mannequin's airway was connected to a test lung, which was pressurized by a Monnal T60 ventilator (Air Liquide Healthcare, Paris, France). The ventilator was set to pressure support

mode with a positive end-expiratory pressure of 20 cm H₂O to simulate airway pressures in ventilated humans. The respiratory rate was set to 1 cycle/min. ETT traction was applied until extubation using a tensile testing machine (Instron-3369, Norwood, Main, USA) which recorded cross member displacement (millimeters) and force (N) with a sampling period of 10 Hz (time increment of 100 ms.). It was connected to an extensometer (Epsilon Technology Corp 3542-050 M-050-ST, Jackson, Wyoming, USA) linked to a test lung allowing measurement of airway pressure. Thus, when the ETT cuff was pulled past the vocal cords, the sudden loss of pressure immediately deflated the test lung, as detected by the extensometer. Extubation was defined as this abrupt drop in airway pressure. All measurement data were acquired in real time by computer.

The adult mannequin was a head with lungs (Laerdal, Stavanger, Norway). A transfixing threaded rod ensured immobility (Fig. 2).

Four configurations were studied within a single session, combining two traction speeds – slow (5 cm/min) and fast (50 cm/min) – with two traction axes: one in the sagittal plane, and the other in the frontal plane, also passing through the mouth (Fig. 3). From our experience, the two planes correspond to distinct types of unplanned extubation risks: patient-related risks in the sagittal plane and care-related risks in the frontal plane. Traction in the sagittal plane better reflects self-extubation, where the patient actively pulls out the endotracheal tube. In contrast, traction in the frontal plane is more representative of accidental extubation caused by external forces—such as forces exerted by the ventilator circuit during patient repositioning, hygiene care, sheet changes, or mobilization in the operating room. This distinction underscored the need to study both planes separately.

To determine the order of testing ETT securing techniques, and to minimize selection bias while ensuring group comparability, computerized randomization was performed, using blocks of seven. A new randomization list was generated for each configuration. The randomization outcome was revealed only after the mannequin had been intubated. Additionally, blinding was maintained between the investigators inserting and securing the ETT (measurement-blinded) and those performing the measurements (blinded to the ETT securing technique). All

<figure><img src="image_4.png" /><figcaption>**Fig. 2.** Unplanned-like extubation procedure. The endotracheal tube, previously sealed, was inserted into the throat of the mannequin (1). It was then gripped to the tensile testing machine (2) and its cuff inflated to 30 cm H₂O (3). The ventilator was set to deliver a constant pressure of 20 cmH₂O (4). The test lung (5) and the extensometer (6) were then under pressure (7). The traction was then applied (8). As soon as the unplanned-like extubation occurred, the airway depressurized, and this was immediately detected by the extensometer. The test lung (5) then returned to its initial position. Thus, the precise moment of the extubation was identified and both displacement and force required for extubation measured.</figcaption></figure>
<figure><img src="image_5.png" /><figcaption>Fig. 3. Traction planes. Traction planes simulating extubation are indicated by the red arrow. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)</figcaption></figure>

measurements were performed in the same room, with the same temperature and moisture condition.

## 2.5. Variables

For each test, we collected the critical peak force required for extubation (hereafter referred to as force<sub>extubation</sub>, expressed in Newtons), the associated displacement (displacement<sub>extubation</sub>, expressed in millimeters), and the elapsed time (in seconds) at the moment of extubation. For each measurement, a graph displaying the relationship between force and displacement was produced.

## 2.6. Study outcomes

The primary objective was to compare ETT securing techniques in terms of force<sub>extubation</sub>. Two distinct traction planes were assessed. The secondary outcomes for this comparison were the displacement<sub>extubation</sub> and the coefficient of variation of force<sub>extubation</sub>, a statistical parameter that quantifies the repeatability (in %) of a technique's behavior when subjected to tensile stress.

## 2.7. Statistical methods

Data were presented as mean ± standard deviation, or median [interquartile range], depending on whether the distribution of the variable was symmetrical or not, as assessed graphically and with the Kolmogorov-Smirnov test. Comparisons used the Wilcoxon test. For multiple comparisons, Dunn's test was used with Bonferroni's adjustment method.

Multivariable linear model has been used to assess the association between each dependent variable (force<sub>extubation</sub> and displacement<sub>extubation</sub>) and independent variables (traction plane, traction speed and securing technique). We also searched for possible interactions and collinearity, assessed using a variance inflation factor > 5.

All tests were two-tailed and *p* < 0.05 was considered significant. No imputation data was carried out. Signal processing was performed with Matlab (MathWorks, Natick, Massachusetts, USA) and the data analysis with R.4.4.1 (R Foundation for Statistical Analysis, Vienna, Austria) [16].

Five measurements were performed for each securing technique under each condition, as this number is generally considered sufficient in standardized repeated-measurement settings [17].

## 3. Results

All 140 tests were completed and there were no measurement failures. Median extubation time, in the sagittal plane, was 3 s [2;5] and 41 s [34;47] for the fast and the slow speeds, respectively, and, in the frontal plane, 14 s [11;16] and 163 s [130;197], respectively.

### 3.1. Primary outcome: comparison of ETT securing techniques

In the sagittal plane, the force<sub>extubation</sub> was significantly higher when using the AnchorFast™ (75 N [52;86]) compared to either adhesive tape techniques: 28 N [19;34] for the short tape (*p* < 0.001), and 34 N [24;45] for the long one (*p* = 0.026). Cord-based techniques were associated with a force<sub>extubation</sub> that did not differ significantly from those of other securing techniques, except in the sagittal plane, where the single cord with a knot significantly outperformed the short adhesive tape (Fig. 4).

In the frontal plane, force<sub>extubation</sub> was higher than in the sagittal plane (115 N [89;148] and 44 N [26;57], respectively, *p* < 0.001), and no significant differences were observed between techniques (Fig. 4).

Overall, force<sub>extubation</sub> was similar when slow or fast speed of traction was applied: 65 N [43;101] or 87 N [35;117], respectively (*p* = 0.76). For each technique, the median overall force<sub>extubation</sub> (irrespective of traction plane or speed), as well as the values relative to traction plane, are reported in Table 1 and Supplemental Fig. 3.

The multivariable model confirmed that both traction plane (*p* < 0.001) and the securing technique (*p* < 0.001) were significantly associated with force<sub>extubation</sub> whereas traction speed was not (*p* = 0.4). No interaction was significant (Supplemental Table 1).

### 3.2. Secondary endpoints

Displacement<sub>extubation</sub> with respect to securing techniques and traction plane are shown in Fig. 5 and Supplemental Table 2. One hundred and twenty-six (90 %) extubations required a displacement >20 mm and 76 (54 %) >50 mm. All the extubations performed in the frontal plane required a > 50 mm displacement. Displacement<sub>extubation</sub> was 32 mm [24;41] in the sagittal plane and 126 mm [100;147] in the frontal one (*p* < 0.001). The multivariable model showed that both the traction plane (*p* < 0.001) and the interaction between traction plane and traction speed have an impact on displacement<sub>extubation</sub> whereas the traction speed (*p* = 0.9) and the securing technique (*p* = 0.074) had not (Supplemental Table 3).

The global coefficients of variation of force<sub>extubation</sub> were 58 % in the sagittal plane and 41 % in the frontal one. Detailed results with respect to securing techniques are presented in Supplemental Table 4.

## 4. Discussion

The main findings of the study could be summarized as follows. In both traction planes, there was no statistically significant difference in force<sub>extubation</sub> between adhesive tape-based techniques and the absence of any securing technique. This suggests that the elastic nature of the tape may allow easier displacement and extubation. In contrast, the AnchorFast™ device outperformed the absence of any securing technique and, in the sagittal plane, adhesive tape-based techniques. Among the cord-based techniques, the single cord with a knot resisted
<figure><img src="image_6.png" /><figcaption>**Fig. 4.** Force<sub>extubation</sub> of each securing technique tested with respect to traction plane. Rank comparison was performed using Wilcoxon test and Dunn's test with Bonferroni's adjustment method for two-by-two comparisons. ETT: endotracheal tube; Force<sub>extubation</sub>, critical peak force required for extubation. ***: *p* < 0.0001; **: *p* < 0.01; *: *p* < 0.5.</figcaption></figure>

<caption>**Table 1**</caption>

Median force<sub>extubation</sub> according to ETT securing techniques and parameters of traction.

<table><thead><tr><th>Securing technique</th><th>Overall n = 140</th><th>Sagittal plane n = 70</th><th>Frontal plane n = 70</th><th>p</th></tr></thead><tbody><tr><td>Control</td><td>28 [15;50]</td><td>15 [9;25]</td><td>50 [36;66]</td><td>&lt;0.001</td></tr><tr><td>AnchorFast™</td><td>100 [75;115]</td><td>75 [52;86]</td><td>113 [101;143]</td><td>&lt;0.001</td></tr><tr><td>Single cord with knot</td><td>92 [60;159]</td><td>44 [30;65]</td><td>138 [88;187]</td><td>&lt;0.001</td></tr><tr><td>Single cord with sheath</td><td>74 [44;139]</td><td>60 [45;73]</td><td>159 [145;161]</td><td>&lt;0.001</td></tr><tr><td>Single cord with elastic tape</td><td>82 [50;157]</td><td>50 [49;55]</td><td>157 [98;177]</td><td>&lt;0.001</td></tr><tr><td>Short elastic adhesive tape</td><td>63 [28;116]</td><td>28 [19;34]</td><td>116 [98;131]</td><td>&lt;0.001</td></tr><tr><td>Long elastic adhesive tape</td><td>49 [34;96]</td><td>34 [24;45]</td><td>96 [91;118]</td><td>&lt;0.001</td></tr></tbody></table>

All values are forces in Newton (N) expressed as median [interquartile range]. Comparisons were performed with Wilcoxon test between the two traction planes.

ETT, endotracheal tube; Force<sub>extubation</sub>, critical peak force required for extubation.

extubation as effectively as the AnchorFast™ device and more effectively than the short adhesive tape. Last, traction applied in the sagittal plane posed a greater overall risk of UE compared to traction in the frontal plane.

To the best of our knowledge, this is the first study to provide a rigorous evaluation method for ETT securing techniques by simulating actual mechanical ventilation conditions as closely as we could. Notably, we found that the arbitrary choice of a fixed tube displacement value is not a reliable option to predict the risk of UE. Indeed, UE<sub>simulation</sub> of the mannequin occurred occasionally below and frequently far beyond the 20-mm displacement threshold commonly retained in previous studies for between-technique comparisons [10,12-14]. Other methodological strengths of the present study include the maintenance

of blinding between the team performing the intubation and securing the tube and the team conducting the tests, thorough inflation of the ETT cuff, and the precise automatic detection of the time of extubation. In contrast, previous studies employed a visual examination to determine that extubation occurred [10,12,14,18]. These methodological differences may explain some discrepancies between our results and earlier findings: during our tests, the AnchorFast™ device [12] and the single cord with a knot [12,13] performed better, while the short elastic tape performed worse [10]. No association between adhesive surface area and force<sub>extubation</sub> force was observed, despite the long elastic adhesive band having a surface area 1.7 times greater than that of the short one [10].

We observed a substantial variability in force<sub>extubation</sub> across securing techniques, with the coefficient of variation differing by a factor of three, despite methodological efforts to maximize reproducibility. When the coefficient of variation was elevated, as with the single cord with sheath, nurses could experience challenges in anticipating the technique's performance, which can be erratic and inconsistent. Additionally, the ETT-only traction tests highlighted the deformable nature of the ETT when subjected to tensile stress. This may partly account for the large displacements observed during tensile testing in the frontal plane, as the traction force was applied to the securing technique-ETT assembly.

The traction plane affected all measured quantities (i.e., displacement<sub>extubation</sub>, and force<sub>extubation</sub>), whereas the traction speed did not. These results are consistent with those reported previously [12]. Displacement<sub>extubation</sub> and force<sub>extubation</sub> were markedly higher when pulling the ETT in the frontal plane than in the sagittal plane. This finding may be translated to clinical practice.

To prevent UE<sub>simulation</sub>, the most effective techniques in terms of force<sub>extubation</sub> were the AnchorFast™ and cord-based ones. Few studies on UE provide detailed information about the types of securing techniques used [4]. It should be noted that these techniques are designed to secure the ETT, not to withstand substantial mechanical loads on the order of several hundred newtons. It may be more beneficial for the technique to yield under such force than to hold on at all costs thereby
<figure><img src="image_7.png" /><figcaption>**Fig. 5.** – Displacement~extubation~ of each securing technique. Red dotted lines indicate the 20 mm and 50 mm extubation thresholds reported in previous studies. Unplanned-like extubations occasionally occurred below the 20 mm threshold, but were more often observed well beyond it—even exceeding 50 mm in the frontal plane. Ranks were compared using Wilcoxon test and Dunn's test with Bonferroni's adjustment method for two-by-two comparisons. The variation coefficient was 42.8 % in sagittal plane and 37.9 % in the frontal one. ETT: endotracheal tube. \*: p < 0.05.</figcaption></figure>

exposing to harmful consequences. In such cases, prescribed extubation or deepening the sedation may be considered [5]. Nursing supervision is therefore a key factor in the occurrence of UE. Constant bedside presence is effective in ensuring patient safety, but it requires sufficient staffing levels, which may be challenging given the high nursing workload reported in recent data [19,20]. The use of physical restraint, which is frequent [21,22], may offer a reassuring sense of security to the nurse, but its effectiveness in preventing UE is questioned [23]. Interestingly, an inversely proportional relationship has been reported between physical restraint and nursing resources [24]. The potential link between work organization, nursing resources and adverse events such as UE is currently under investigation [25].

## 4.1. Study limitations

First, although our comparison focused on the techniques themselves, differences in set-up may also play a role. Tightening and adjustment may vary between operators. In this study, to enhance repeatability, only two operators installed the securing techniques. Second, the assessment was performed on a mannequin made of plastic, a substrate far removed from human tissue. Patient-related parameters such as perspiration, saliva and body hair which could influence the performance of the ETT securing techniques evaluated, were not considered. The aim was to ensure rigorously comparable evaluation conditions between the different techniques. Additionally, during surgical procedures close to the securing technique (neck, spine, face, neurosurgery, e.g.), the use of alcohol-based antiseptic solutions may promote the detachment of elastic adhesive techniques. Non-adhesive systems passing behind the neck may be too close of the surgical site. Nevertheless, the tape-based techniques assessed have been shown to perform poorly, and there is no evidence to suggest that their effectiveness would improve under humid and/or hairy conditions. Third, the precise mechanism of technique failure has not been collected. In our investigator-related experience, elastic adhesive tapes-based techniques generally held, but stretched excessively. Cord-based techniques either

broke near the knot or the tube slipped out. The AnchorFast™ device broke with the sticky part coming off the sliding bar. Fourth, the present study evaluated only a single model of elastic adhesive tape and one model of cord; therefore, the conclusions cannot be generalized to all types of tapes and cords. Fifth, our study focused on the risk of UE and did not assess the ability of securing techniques to prevent ETT displacement leading to selective bronchial intubation, nor did it evaluate their ability to prevent minor ETT displacements. To mitigate these adverse events, elastic adhesive tapes may offer some benefit compared to the absence of any securing technique. Sixth, the force~extubation~ levels we report did not account for the influence of the ventilation circuit or the robustness of its connection to the ETT. However, in our opinion, this limitation is unlikely to have biased our comparisons between devices. Last, our study design did not permit the evaluation of patient's or healthcare providers' comfort and experience.

## 5. Conclusion

ETT securing techniques using elastic adhesive tape were less effective at preventing UE~simulation~ than either the AnchorFast™ device or a single cord with a knot. This experimental study provides a necessary basis for future clinical research.

## Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Clinical trial registration

Not applicable.

## CRediT authorship contribution statement

Jérôme E. Dauvergne: Writing – original draft, Visualization,
Supervision, Methodology, Investigation, Formal analysis, Conceptualization. **Yvan Derouin:** Writing – review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. **Frédéric Marie:** Writing – review & editing, Investigation. **Olivier Bazin:** Writing – review & editing, Investigation. **Bertrand Rozek:** Writing – review & editing, Validation. **Eric Courteille:** Writing – review & editing, Validation. **Karim Lakhal:** Writing – original draft, Validation, Supervision, Methodology. **Ronan Le Breton:** Writing – review & editing, Validation, Supervision, Investigation.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jérôme E. Dauvergne, Yvan Derouin, Frederic Marie, Olivier Bazin, Eric Courteille and Ronan Le Breton have no conflict of interest in connection with the work submitted. Karim Lakhal has no conflict of interest in connection with the work submitted. In addition, KL declares having received consulting fees from Philips since 2024. Over the past three years, KL has also received congress registration support from Pfizer (once in 2022), as well as congress registration and travel fees from Advanz Pharma/Correvio (once in 2024) and AOP Health (once in 2024). Bertrand Rozek has no conflict of interest in connection with the work submitted. In addition, BR received, during the past 5 years, lecture fees from Fisher&Paykel, Baxter, LFB, and Aspen, research grants from Baxter and Aguettant, and consulting fees from LFB, Aguettant, and Astra Zeneca.

If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.)

Data availability statement

The datasets analyzed during the current study are available from the
corresponding author.

Acknowledgements

We would like to sincerely thank Hollister®, who kindly provided us
with samples of their commercial securing technique AnchorFast™ for
the measurements. We would especially like to thank Lou Gauthier and
Marwen Jabbar, the two students involved in this project.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jcrc.2025.155332.

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