Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children

Lorri M Phipps, Neal J Thomas, Raymond K Gilmore, Jill A Raymond, Toni R Bittner, Richard A Orr, Courtney L Robertson
Pediatric Critical Care Medicine 2005, 6 (5): 519-22

OBJECTIVE: To determine whether multiplying the internal diameter of the endotracheal tube (ETT) by 3 (3x ETT size) is a reliable method for determining correct depth of oral ETT placement in the pediatric population.

DESIGN: Prospective, observational.

SETTING: University-affiliated, 12-bed pediatric intensive care unit.

PATIENTS: Orally intubated pediatric intensive care unit patients of < or =12 yrs of age.

INTERVENTIONS: Demographics, ETT size, and depth of ETT placement measured from the lip were obtained. Correct placement, defined as the tip of the ETT below the thoracic inlet and > or =0.5 cm above the carina, was determined by chest radiograph.

MEASUREMENTS AND MAIN RESULTS: Suggested ETT size based on the Pediatric Advanced Life Support (PALS) age-based formula and the Broselow tape-length-based guidelines were determined. A total of 174 of 226 ETTs (77%) were correctly positioned. If practitioners utilized the 3x ETT size for the actual tubes chosen, 170 of 226 (75%) would have been accurately placed. More accurate were the 3x PALS-based ETT size (81%) and 3x Broselow-suggested ETT size (85%). The use of the Broselow ETTs to determine the depth would have led to a significantly improved ETT position (p = .009) compared with the actual ETT.

CONCLUSION: The commonly used formula of 3x tube size for ETT depth in children results in 15-25% malpositioned tubes. Practitioners can improve the reliability of this formula by utilizing the recommended ETT size as suggested by the Broselow tape. A more reliable method is necessary to avoid ETT malposition.

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