Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement

Abstract

Purpose: To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population.Methods: Chest radiographs from 257 children (age 12 days-12 yr), who presented for a total of 446 individual procedures in the fluoroscopy suite, were studied to determine the incidence of ETTs placed too shallow (above the inferior clavicular border) or too deep (at or below the carina). A logistic regression with outcomes of correct and incorrect was used to analyze the data points. Results:Eighteen percent of all the radiographs showed initial improper ETT placement, despite clinical evidence suggesting the contrary. The peak incidence of malposition, which occurred in patients under one year old, reached 35%. Incidence decreased with advancing age, but remained over 10% until the age of ten. A second attempt at positioning the tube, based on information from the chest radiograph, was successful in 95% of the cases. The remaining 5% required placement of the ETT under continuous fluoroscopic guidance. Conclusion

Factors Associated with Misplaced Endotracheal Tubes During Intubation in Pediatric Patients

“…The level of training of the intubator has also been shown by both Sagarin et al and Kerrey et al to affect first attempt success (10,13). However, data suggest that malposition can occur frequently even when performed by experts in airway management: in a study of 257 pediatric patients intubated in the operating room by anesthesiologists, malposition of the ETT occurred in 18% of cases, with an even higher incidence (35%) among patients <1 year of age (12).…”

“…We subcategorized misplaced ETTs as high or low and estimated a multivariable multinomial logistic regression with our primary outcome, ETT misplacement, as the dependent variable and selected patient and procedural features as the independent variables. We decided a priori to include age and sex in the multivariable model based on published data showing relationships between these patient characteristics and intubation performance (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)14). In addition, we included any patient or procedural features with a p value of < 0.1 in univariate testing as potential predictors.…”

Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography

“…On the other hand, an ETT placed too high in the trachea carries risks of accidental extubation and cuff-induced vocal cord injury. Confirmation of correct position can be difficult in the emergency department: background noise interferes with auscultation, [35][36][37] capnography does not distinguish between endobronchial and endotracheal intubation, 38,39 and radiographic studies entail some finite delays. 12 Direct or fibre-optic visualization is also imperfect.…”

Usage of a fibreoptic scope to verify tracheal tube placement in the pediatric population

“…Also, misplacement occurred in 37.7% of the children who were less than 1-year-old. Since the reliability of mathematical formulae and clinical auscultation to estimate the proper depth of tracheal tube insertion has not been proven, Harris et al 1 advocate increased usage of fluoroscopy/radiography to confirm tracheal tube placement in pediatric surgical cases.…”

“…1 Eighteen percent of the 257 chest radiographs from intubated children showed misplacement of tracheal tubes. Thirteen percent of the radiographs were too deep, while 5% were too shallow.…”