Weight-Based Guide Overestimates Endotracheal Tube Tip Position in Extremely Preterm Infants

Abstract

Objective To evaluate the association between endotracheal tube (ETT) tip position and adverse pulmonary outcomes using chest X-ray (CXR) in extremely preterm infants in whom ETT insertion length was estimated using weight + 6 guide (adding 6 cms to the infant’s weight in kg). Study Design CXRs of 85 infants performed in the first week were reviewed for right-sided atelectasis, air leaks, and uneven lung inflation. The first CXR was later reviewed to document the ETT tip. Regression analysis was performed to find the association between ETT tip position and adverse outcome after adjusting for other confounders. Results Forty (46%) infants had ETT tip placement between the first and second thoracic vertebrae (optimal position) compared with 45 (53%) who had the ETT tip placement outside this range (suboptimal position). Infants with suboptimal ETT were ventilated for a longer period (6.1 vs. 15.9 days; p = 0.004). The odds of adverse outcomes was 11.6 (95% confidence interval: 3.03, 44.1) times higher among infants who did not have ETT at the optimal position compared with infants who had ETT at the optimal position. Conclusion Weight + 6 guide is not recommended to estimate ETT insertion length in extremely preterm infants. Gestation-based guide may be more appropriate to estimate ETT insertion length in this group of infants.

Ultrasonography for Determining Endotracheal Tube Tip Position in Very Low Birth Weight Infants

“…However, CXR also has disadvantages, such as not giving instant information about the ETT tip, which can be malpositioned even when the baby turns his head. 10,12 In addition, the time elapsed between intubation and CXR interpretation may cause a late evaluation of placement. Also, radiation exposure is increased when CXRs are repeated.…”

“…In CXR, the ETT tip placed between the first and third thoracic vertebra is classified as appropriate placement. However, CXR also has disadvantages, such as not giving instant information about the ETT tip, which can be malpositioned even when the baby turns his head 10,12 . In addition, the time elapsed between intubation and CXR interpretation may cause a late evaluation of placement.…”

Airway management in neonates and infants

“…Evidence summary: Malposition of the tracheal tube in infants can lead to life-threatening complications including hypo-xaemia, pneumothorax, and unintentional extubation 109,110 . A method for estimating appropriate insertion depth of a tracheal tube in neonates has been extensively studied (Supplementary Table S17, http://links.lww.com/EJA/A891).…”

“…Evidence summary: Malposition of the tracheal tube in infants can lead to life-threatening complications including hypo-xaemia, pneumothorax, and unintentional extubation. 109,110 A method for estimating appropriate insertion depth of a tracheal tube in neonates has been extensively studied (Supplementary Table S17, http:// links.lww.com/EJA/A891). Despite antero-posterior chest radiography considered as the gold standard for determining correct tracheal tube tip position, 106,111,112 there are limitations to this method, including lack of immediacy, no definite interpretation guidelines, and radiation exposure.…”

Ultraschallgestützte Lagekontrolle des Endotrachealtubus bei Neugeborenen

“…Es existieren Standardwerte für die Intubationstiefe nach Gestationsalter und Geburtsgewicht [4]. Allerdings lassen Standardwerte individuelle anatomische Unterschiede außer Acht, weshalb sie nur als Richtwerte dienen können und keine radiologische Lagekontrolle ersetzen [5].…”