Randomised trial of estimating oral endotracheal tube insertion depth in newborns using suprasternal palpation of the tip or weight

Abstract

BackgroundEndotracheal tube (ETT) tip position is determined on chest X-ray (CXR) and should lie between the upper border of the first thoracic vertebra (T1) and the lower border of second thoracic vertebra (T2). Infant weight is commonly used to estimate how far the ETT should be inserted but frequently results in malpositioned ETT tips. Palpation of the ETT tip at the suprasternal notch has been recommended as an alternative.ObjectiveTo determine whether estimating ETT insertion depth using suprasternal palpation of the ETT tip rather than weight results in more correctly positioned ETT tips.DesignSingle-centre randomised controlled trial.SettingLevel III neonatal intensive care unit (NICU) at a university maternity hospital.PatientsNewborn infants without congenital anomalies intubated in the NICU.InterventionsParticipants were randomised to have ETT insertion depth estimated using palpation of the ETT tip at the suprasternal notch or weight [insertion depth (cm)=6 + wt (kg)].Main outcome measureCorrect ETT position, that is, between the upper border of T1 and lower border of T2 on CXR, determined by one consultant paediatric radiologist masked to group assignment.ResultsThere was no difference in the proportion of correctly placed ETT tips between the groups (suprasternal palpation 27/58 (47%) vs weight 23/60 (38%), p=0.456). Most incorrectly positioned ETTs were too low (56/68 (82%)).ConclusionEstimating ETT insertion depth using suprasternal palpation did not result in more correctly positioned ETTs.Trial registration numberISRCTN13570106.

Methods for Estimating Endotracheal Tube Insertion Depth in Neonates: A Systematic Review and Meta-Analysis

“…Eight studies were included in the qualitative analysis. [7][8][9][14][15][16][17][18] The list of studies excluded following a detailed review, including the reasons for exclusion, is provided in ►Supplementary Material D (available in the online version). In ►Table 1, details of the included studies are presented.…”

“…Seven different estimation methods were compared in the eight included trials for estimating the endotracheal tube insertion depth. Six trials compared weight-based method (weight in kilograms þ 6 cm) with various other methods (digital palpation, 9,17,18 vocal cord guide, 8 gestation nomogram, 7 and foot length 15 ), one trial 14 compared two different weightbased methods (weight in kilograms þ 6 cm vs. weight in kilograms þ 5.5 cm), 14 and one compared the vocal cord guide with the TRACH MATE endotracheal tube method. 16 The gestational age of the neonatal population among included trials was between 29 and 32 weeks.…”

“…16 The gestational age of the neonatal population among included trials was between 29 and 32 weeks. [7][8][9]14,15,17,18 One trial 16 included older infants (mean gestational age 34 weeks) compared with other included studies.…”

“…Blinding of outcome assessment: Five trials blinded the primary outcome. [7][8][9]17,18 It was unclear in the other three studies. [14][15][16] The risk assessment was unclear for all the secondary outcomes.…”

“…Three trials used carina as a lower landmark, and defined optimal endotracheal tube tip placement 0.5 16 or 1 cm, 9,17 above the carina. Similarly, four trials utilized T1 vertebra as an upper landmark (body 16 or upper border 7,8,18 of the T1 vertebra). On the contrary, few trials utilized a single landmark point to define optimal endotracheal tube tip placement (T1 15 and T2 14 vertebral body).…”