Document Type : original article
Authors
1 Clinical Research Development Unit of Zahra Mardani Azari Children Educational and Treatment Center, Tabriz University of Medical Sciences, Tabriz, Iran
2 Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Abstract
Background: In the process of intubation, inappropriate placement of the endotracheal tube can lead to hypoxemia, aspiration, insufficient ventilation, atelectasis, barotrauma and pneumothorax. The above complications may be difficult for a patient with severe disease to tolerate; especially when inappropriate placement is not detected by the specialist in the initial evaluation and the diagnosis lasts until the confirmatory chest x-ray is performed. This study evaluated the validity of three formulas in measuring the depth of endotracheal intubation in children under mechanical ventilation.
Methods: 60 intubated children aged 2 months to 12 years were included in this study. The patients were randomly divided into three study groups. Endotracheal tube length for each patient was calculated on the basis of the endotracheal tube length formulas (12 + age (years) / 2; endotracheal tube diameter * 3; and 5 + height (cm) / 10). The ideal depth of the endotracheal tube based on chest x-ray was measured as the median distance between the first thoracic vertebra (T1) and the carina in cm. The distance between the ideal depth of the endotracheal tube and the end location of the endotracheal tube was also measured and recorded.
Results: The mean age of the patients was 42.90 months and 58.3% of them were boys. The most common indication for intubation was pneumonia, along with respiratory distress (33.3%). Considering the difference in endotracheal tube depth between the two values calculated using the formula and chest X-ray equal to± 0.5 cm, formula 12 + (2 / age) in 55% of patients, formula 3 * endotracheal tube length in 70% patients and formula 5 + (10 / height) in 85% of patients, were correctly estimated endotracheal tube length. On the other hand, it was observed that in 15%, 45% and 40% of the patients, the formula predicted the correct length of the endotracheal tube for correct intubation without any difference while compared to the chest X-ray. In evaluating the results obtained from the formula and length of the endotracheal tube measured by chest X-ray, it was also observed that the formulas 12 + (2 / age), 3 * length of the endotracheal tube and 5 + (10 / height) were significantly correlated with CXR.
Conclusion: According to the obtained results, it can be concluded that the formulas used to estimate the depth of endotracheal tube placement in children have low accuracies compared to the gold standard of measurement (chest X-ray). Of course, in comparison to the three formulas (height, weight and diameter of the ETT), the height formula was more accurate than others.
Keywords
- Magill IW. Technique in endotracheal anesthesia. British medical journal. 1930; 2(3645):817.
- Ayre P. Endotracheal Anesthesia for Babies: With Special Reference to Hare-Lip and Cleft Palate Operations. Anesthesia & Analgesia. 1937; 16(6):330-3.
- Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: the debate should finally end. The Journal of the American Society of Anesthesiologists. 2013; 118(3):500-1.
- Rafiq M, Wani TM, Moore-Clingenpeel M, Tobias JD. Endotracheal tubes and the cricoid: Is there a good fit? International Journal of Pediatric Otorhinolaryngology. 2016; 85:8-11.
- Ho AH, Aun CST, Karmakar MK. The margin of safety associated with the use of cuffed pediatric tracheal tubes. Anaesthesia. 2002; 57(2):169-282.
- Bhardwaj N. Pediatric cuffed endotracheal tubes. Journal of anaesthesiology, clinical pharmacology. 2013; 29(1):13.
- Felten M-L, Schmautz E, Delaporte-Cerceau S, Orliaguet GA, Carli PA. Endotracheal tube cuff pressure is unpredictable in children. Anesthesia & Analgesia. 2003; 97(6):1612-6.
- Taylor C, Subaiya L, Corsino D. Pediatric cuffed endotracheal tubes: an evolution of care. Ochsner Journal. 2011; 11(1):52-6.
- Birmingham PK, Cheney FW, Ward RJ. Esophageal intubation: a review of detection techniques. Anesthesia & Analgesia. 1986; 65(8):886-91.
- Knapp S, Kofler J, Stoiser B, Thalhammer F, Burgmann H, Posch M, Hofbauer R, Stanzel M, Frass M. The assessment of four different methods to verify tracheal tube placement in the critical care setting. Anesthesia & Analgesia. 1999; 88(4):766-70.
- Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, Gonano C, Weinstabl C, Kettner SC. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomized trial. Bmj. 2010; 341.
- Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of emergency medicine. 2001; 37(1):32-7.
- Lotano R, Gerber D, Aseron C, Santarelli R, Pratter M. Utility of postintubation chest radiographs in the intensive care unit. Critical Care. 2000; 4(1):1-4.
- McGillicuddy DC, Babineau MR, Fisher J, Ban K, Sanchez LD. Is a postintubation chest radiograph necessary in the emergency department? International journal of emergency medicine. 2009; 2(4):247-9.
- Donoghue A. Airway Management Outside of the Operating Room: the Emergency Department. Management of the Difficult Pediatric Airway. 2019:177.
- Lee SU, Jung JY, Kim DK, Kwak YH, Kwon H, Cho JH, Park JW, Choi YJ. New decision formulas for predicting endotracheal tube depth in children: analysis of neck CT images. Emergency medicine journal: EMJ. 2018; 35(5):303-8.
- Tochen ML. Orotracheal intubation in the newborn infant: a method for determining depth of tube insertion. The Journal of pediatrics. 1979; 95(6):1050-1.
- Morgan GAR, Steward DJ. Linear airway dimensions in children: including those with cleft palate. Canadian Anesthetists’ Society Journal. 1982; 29(1):1-8.
- Santos DLS, Andrade PDdO, Gomes ELdFD. Does the endotracheal tube insertion depth predicted by formulas in children have a good concordance with the ideal position observed by X-ray? Revista Brasileira de Terapia Intensiva. 2020; 32:295-300.
- Koshy T, Misra S, Chatterjee N, Dharan BS. Accuracy of a chest x-ray–based method for predicting the depth of insertion of endotracheal tubes in pediatric patients undergoing cardiac surgery. Journal of cardiothoracic and vascular anesthesia. 2016; 30(4):947-53.
- Akhgar A, Bahrami S, Mohammadinejad P, Khazaeipour Z, Hossein H. A New Formula for Confirmation of Proper Endotracheal Tube Placement with Ultrasonography. Advanced Journal of Emergency Medicine. 2019; 3(3).
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