A New Formula for Confirmation of Proper Endotracheal Tube Placement with Ultrasonography
Background Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as failure of intubation. This failure rate was 9.9% in the standard method which would have been 1.1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings.
2. Bahar İ, Elay G, Coşkun R, Gündoğan K, Güven M, Sungur M. Complications of Endotracheal Intubation in the Intensive Care Unit: A Single-center Experience after Training. Erciyes Med J. 2015;37(4):133-7.
3. Link M, Berkow L, Kudenchuk P, Halperin H, Hess E, Moitra V, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S444.
4. Collins S, Blank R. Fiberoptic intubation: an overview and update. Respir Care. 2014;59(6):865-78.
5. Chou H-C, Tseng W-P, Wang C-H, Ma MH-M, Wang H-P, Huang P-C, et al. Tracheal rapid ultrasound exam (TRUE) for confirming endotracheal tube placement during emergency intubation. Resuscitation. 2011;82(10):1279-84.
6. Visser R, Danzl D. Intubation and Mechanical Ventilation. Tintinallis Emergency Medicine: A Comprehensive study Guide. 8 ed2016.
7. Robert J. Tracheal Intubation. Robert and Hedges’ Clinical procedures in Emergency Medicine. 6 ed2014.
8. Nasim F, Chae J, Goel S. Endotracheal intubation in critically iII patients: Direct laryngoscopy, complications, and cardiac arrest. Am J Respir Crit Care Med. 2018;197(12):1625-7.
9. Hossein-Nejad H, Payandemehr P, Bashiri S, Nedai H. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med. 2013;31(8):1181-2.
10. Ahmadi K, Ramezani M, Ebrahimi M. Ultrasound as a Secondary Confirmation Method after Endotracheal Intubation. Med J Mashhad Uni Med Sci. 2013;56(4):236-42.
11. Hosseini JS, Talebian MT, Ghafari MH, Eslami V. Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view. Int J Crit Illn Inj Sci. 2013;3(2):113-7.
12. Werner SL, Smith CE, Goldstein JR, Jones RA, Cydulka RK. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. 2007;49(1):75-80.
13. Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign. Acad Emerg Med. 2006;13(3):239-44.
14. Evron S, Weisenberg M, Harow E, Khazin V, Szmuk P, Gavish D, et al. Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements. J Clin Anesth. 2007;19(1):15-9.
15. Varshney M, Sharma K, Kumar R, Varshney PG. Appropriate depth of placement of oral endotracheal tube and its possible determinants in Indian adult patients. Indian J Anaesth. 2011;55(5):488-93.