Upper lip pressure ulcers in very low birth weight infants due to fixation of the endotracheal tube

Pressure ulcers of the upper lip developed in five very low birth weight infants due to fixation of the endotracheal tube. These ulcers left marked scars on the lip, and one patient required revision surgery. All cases occurred in infants whose birth weight was less than 1200 g, and whose gestational age was less than 29 weeks. We investigated these unusual ulcers and concluded that they were not caused by simple pressure but by a shearing force to the lips during fixation of the endotracheal tube. To prevent such pressure ulcers, a new method to stabilize the endotracheal tube is presented in which a flexible laminated arch is laid across the mouth and held to both cheek with adhesive tape and to which the intubation tube is tied.We warn about the possible complication and recommend this method to prevent undesirable iatrogenic incidents, especially for very low birth weight neonates.