Routine chest radiographs following repositioning of endotracheal tubes are necessary to assess correct position in pediatric patients

Comparison of four formulas for nasotracheal tube length estimation in pediatric patients: an observational study

BACKGROUND

Correct endotracheal intubation results in better ventilation, prevents hypoxia and its possible damages, such as brain injury, and minimizes attempts for re-intubation. Up to now, several formulas have been published to estimate nasotracheal intubation tube length. This study aims to compare the accuracy of different suggested formulas to find the one that better estimates the tube insertion distance.

METHODS

This cross-sectional retrospective study was carried out in 102 (51 female, 51 male) children who underwent cardiac surgery under general anesthesia. Inclusion criteria were correct nasotracheal intubation according to the postintubation chest X-ray (CXR). The estimated tracheal tube length was calculated by four different formulas. Pearson...s correlation coefficient was used to find the correlations between the estimated length of each formula and the correct nasotracheal tube length. Also, linear regression was used to obtain a formula to estimate nasotracheal tube length by weight, height, and age.

RESULTS

The formula L=3*tube size+2 had the best correlation with tube length (r ...=...0.81, Confidence Interval: 0.732...0.878, p-value < 0.001). Among demographic variables, height had the highest correlation coefficient with the tube length (r...=...0.83, Confidence Interval: 0.788...0.802, p-value < 0.001). Therefore, considering the height as an independent variable and tube length as a dependent variable, using linear regression, the following formula was achieved for determining tube length: nasotracheal tube length...=...0.1*Height+7.

CONCLUSIONS

The formula L=3*tube size+2 and the new suggested formula in this study can be used to estimate nasotracheal tube length in children under 4 years old. However, these formulas are only guides and require confirmation by auscultation and CXR.

Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study

Introduction

The chest X-ray (CXR) is the standard of practice to assess the tip of the endotracheal tube (ETT) in ventilated children. In many hospitals, it takes hours to get a bedside CXR, and it has radiation exposure. The objective of this study was to find the utility of bedside ultrasound (USG), in assessing the ETT tip position in a Pediatric Intensive Care Unit (PICU).

Methods

It was a prospective study conducted in the PICU of a tertiary care center involving 135 children aged from 1 month to 60 months, requiring endotracheal intubation. In this study, the authors compared the position of the ETT tip by the CXR (gold standard) and USG. The CXR was taken in children to assess the correct position of the tip of ETT. The USG was used to measure the distance between the tip of ETT and the arch of the aorta, thrice in the same patient. The mean of the three USG readings was compared with the distance between the tip of the ETT and carina in CXR.

Results

The reliability of three USG readings was tested by absolute agreement coefficient in intraclass correlation (ICC), 0.986 (95% CI: 0.981-0.989). The sensitivity and specificity of the USG in identifying the correct position of the ETT tip in children when compared to CXR were 98.10% (95% CI: 93.297-99.71%) and 50.0% (95% CI: 31.30-68.70%), respectively.

Conclusion

In ventilated children <60 months of age, identifying the tip of ETTs by bedside the USG has good sensitivity (98.10%) but poor specificity (50.0%).

How to cite this article

Subramani S, Parameswaran N, Ananthkrishnan R, Abraham S, Chidambaram M, Rameshkumar R, et al. Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study. Indian J Crit Care Med 2022;26(11):1218-1224.

Evaluating the Practice of Repositioning Endotracheal Tubes in Neonates and Children Based on Radiographic Location

OBJECTIVES

Chest radiographs are commonly performed in the ICU setting to confirm the position of the endotracheal tube. The purpose of this study was to evaluate the practice and accuracy of repositioning endotracheal tubes in the pediatric population based on chest radiograph.

DESIGN

Retrospective review of patient's medical record and chest radiograph.

SETTING

Single-institution, academic children's hospital.

PATIENTS

PICU and cardiothoracic ICU patients who had repositioning of their endotracheal tube from September 1, 2016, to September 1, 2017.

MEASUREMENTS AND MAIN RESULTS

Chest radiograph before and after endotracheal tube repositioning were examined measuring the distance from the endotracheal tube tip to carina. A total of 183 endotracheal tube repositionings were assessed. Twenty-nine percent of endotracheal tube repositionings resulted in a persistently malpositioned endotracheal tube, requiring another intervention. For intended endotracheal tube repositioning of ± 2.0 cm, the actual change measured compared to intended adjustment was a median of 0.7 cm (interquartile range, 0.35-1.1 cm). For intended ± 1.5 cm, the median difference was 0.4 cm (interquartile range, 0.16-0.90 cm). For intended ± 1.0 cm, the median difference was 0.5 cm (interquartile range, 0.20-0.90 cm). For intended ± 0.5 cm, the median difference was 0.3 cm (interquartile range, 0.2-0.88 cm). When the head was malpositioned the difference from intended endotracheal tube repositioning to actual was median 0.70 cm (interquartile range, 0.40-1.1 cm), this was significantly higher than when the head was in a good position CONCLUSIONS:: When repositioning endotracheal tubes based on chest radiograph, there is a significant difference between intended and actual adjustment with great variability. Avoiding very small repositionings (± 0.5 cm) and standardizing head position prior to daily chest radiograph may reduce these errors.

Pulmonary atelectasis in newborns with clinically treatable diseases who are on mechanical ventilation: clinical and radiological aspects

Objective

To analyze the radiological aspects of pulmonary atelectasis in newborns on mechanical ventilation and treated in an intensive care unit, associating the characteristics of atelectasis with the positioning of the head and endotracheal tube seen on the chest X-ray, as well as with the clinical variables.

Materials and Methods

This was a retrospective cross-sectional study of 60 newborns treated between 1985 and 2015. Data were collected from medical records and radiology reports. To identify associations between variables, we used Fisher's exact test. The level of significance was set at p < 0.05.

Results

The clinical characteristics associated with improper positioning of the endotracheal tube were prematurity and a birth weight of less than 1000 g. Among the newborns evaluated, the most common comorbidity was hyaline membrane disease. Atelectasis was seen most frequently in the right upper lobe, although cases of total atelectasis were more common in the left lung. Malpositioning of the head showed a trend toward an association with atelectasis in the left upper lobe.

Conclusion

Pulmonary atelectasis is a common complication in newborns on mechanical ventilation. Radiological evaluation of the endotracheal tube placement provides relevant information for the early correction of this condition.

Accuracy of a Chest X-Ray-Based Method for Predicting the Depth of Insertion of Endotracheal Tubes in Pediatric Patients Undergoing Cardiac Surgery

OBJECTIVES

The incidence of endotracheal tube (ETT) malposition in children with various described methods is 15% to 30%. Chest x-ray (CXR) is the gold standard for confirming appropriate ETT position. The aim of this study was to measure the accuracy of a preoperative CXR-based method in determining depth of insertion of ETTs and to compare it with methods based on the intubation depth mark or formulae (age, height, and ETT internal diameter) in children undergoing cardiac surgery.

DESIGN

Prospective observational study.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS

Sixty-six consecutive children scheduled for elective pediatric cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The distance from carina to mid-trachea was measured for each child preoperatively on the CXR displayed as a computed radiography image in a picture archival and communications system computer. Following intubation, ETTs deliberately were pushed endobronchially and then pulled back to the carina; they were further withdrawn by the previously measured carina to mid-tracheal distance and secured. CXRs postoperatively were repeated to confirm ETT position. The ETT position was measured with other methods using the picture archival and communications system ruler on the postoperative CXR and compared with the CXR method. The proportion of appropriate ETT position with the CXR method was 98.5% (p≤0.001 v other methods). In children younger than 3 years, the appropriate proportion was 97.4%.

CONCLUSION

The appropriate positioning of ETTs in the trachea by the CXR method is superior to other methods.

The impact of postintubation chest radiograph during pediatric and neonatal critical care transport

OBJECTIVES

Tracheal intubation is necessary in the setting of pediatric/neonatal critical care transport but information regarding usefulness and efficiency of a confirmatory postintubation chest radiograph is limited. We hypothesize that routine postintubation chest radiograph to confirm tracheal tube position is not informative and can be eliminated to improve efficiency without compromising safety in transport.

DESIGN

This was a prospective observational study. The primary study outcome was the rate of tracheal tube repositioning after postintubation chest radiograph and the secondary outcome was the on-scene time. Additional data obtained included the initial accuracy of tracheal tube depth based on Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines.

SETTING

A children's hospital-based pediatric/neonatal critical care transport team in northeastern Ohio.

PATIENTS

All pediatric/neonatal patients intubated by the transport team during the 18-month study period (January 2009-July 2010).

MEASUREMENTS AND MAIN RESULTS

There were 77 patients enrolled (43 pediatric, 34 neonatal). A postintubation chest radiograph was obtained 85.7% of the time and showed tracheal tube malposition in 47% of cases. No difference was seen in the rate of malpositioned tracheal tubes in the neonatal group compared with pediatric group (51.7% vs. 43.2%, p = 0.54). The calculated tracheal tube depth based on the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines was correct in 50% of the neonates and 41.9% of the pediatric patients. In patients with appropriate initial tracheal tube depth by calculations, the tracheal tube was repositioned at similar rates after postintubation chest radiograph in both neonatal and pediatric patients (50% vs. 41.9%, p = 0.48). When comparing mean onscene times for patients with/without a postintubation chest radiograph, the neonatal patients saved 33 minutes on average when no chest radiograph was obtained (mean ± sd: 60.6 ± 35.8 min vs. 93.8 ± 23.8 min, p = 0.01). There was no statistical difference in on-scene time for pediatric patients whether they did or did not receive a postintubation chest radiograph.

CONCLUSIONS

Although postintubation chest radiographs may extend the overall on-scene transport times in select patients, our data show that the postintubation chest radiographs remain informative in pediatric/neonatal critical care specialty transport and should be obtained when feasible.

Intubation practice patterns in Tuscan emergency departments

Introduction

Intubation is one of the most important life-saving procedures performed by emergency physicians (EPs). There is variation in practice when different countries are compared.

Methods

A written questionnaire on intubation practices was administered to a group of Italian doctors practicing in Tuscany during the examination period of a year-long course in emergency medicine.

Results

The survey was administered to 153 participants. Of these, 143 (93.4%) returned a complete survey. In the sub-group of physicians who work in the emergency department (ED), 73.6% report intubating patients. Of those that intubate patients, 92.3% use some sort of sedation, and 49.3% use paralytics. While direct visualization of the cords for intubation and auscultation of breath sounds after intubation are almost universal (97% and 100%, respectively), only 11.9% use colorimetric CO2 detectors for confirmation of intubation. After intubation 58.2% commonly place a nasogastric tube and 50.7% obtain a post intubation chest radiograph.

Conclusions

Practice patterns in the USA and Tuscany are different. RSI and post-intubation radiographs are the standard of care in EDs in the USA. This is not the case in Tuscany.

Estimation of the length of nasotracheal tube to be introduced in children

The formula 10.5 + (weight[kg]/2) showed a predictive capacity of 0.8939 to estimate the length (cm) of endotracheal tube to be introduced through the nasal route in 99 children between newborn and 4 years old. In a validation study, the formula maintained a high level of concordance with the true values: 0.9370.

Prospective study of airway management of children requiring endotracheal intubation before admission to a pediatric intensive care unit

OBJECTIVE

To prospectively identify complications related to airway management in children before pediatric intensive care unit (ICU) admission.

DESIGN

A descriptive, prospective study covering an 18-month period. A survey was completed at the time of admission to obtain demographic data, reason for endotracheal (ET) intubation, medications administered, location of and personnel responsible for ET intubation, and major/minor variances associated with airway management. Major variances were defined as technical problems resulting in a significant risk for airway trauma and increased morbidity. Minor variances were problems that should be avoided, but which do not significantly increase the immediate risk to the patient. Additional information obtained included whether a chest radiograph (CXR) was obtained and if postextubation problems occurred, such as stridor requiring treatment or reintubation.

SETTING

Community hospitals, emergency rooms, children's hospital emergency rooms

PATIENTS

All children < or =18 yrs of age receiving ET intubation before admission to the pediatric ICU, except those in cardiovascular arrest.

MEASUREMENTS AND MAIN RESULTS

Data were collected on 250 consecutive patients. Major or minor variances were noted in 135 (54%) patients and in 66% of patients < or =1 yr of age (p = .02865; odds ratio, 2.0). Twenty-six percent of patients < or =1 yr of age received an anticholinergic agent before ET intubation compared with 40% of older patients (p = .04343; odds ratio, 0.504). Eleven patients received a neuromuscular blocking agent (NMBA) without a sedative/analgesic agent. Major variances occurred in 54% of patients who did not receive a NMBA and in 27% of patients who received a NMBA (p = .00002; odds ratio, 0.307). Forty-one patients (16%) were intubated with an inappropriately sized ET tube. Postintubation CXRs were obtained in 65% of patients managed outside of a children's hospital and in 93% of patients in a children's hospital emergency room (p < .00001; odds ratio, 7.199). Variances detectable by CXR went unrecognized in 40% of patients, despite obtaining a CXR.

CONCLUSIONS

Emergency airway management in children can be fraught with problems. Most variances could be avoided by improved education regarding appropriate ET tube size, appropriate medication use, and improved training for evaluation of ET tube placement.