Evaluation of manual cuff palpation to confirm proper endotracheal tube depth

In the prehospital setting, optimal endotracheal tube (ETT) depth may be approximated using the patient's sex or height, and assessed by auscultation. Even when using these methods, the ETTs still may be placed at inappropriate depths.

This study assessed the inter-rater reliability and accuracy of manual cuff palpation (ballottement) at excluding an improperly placed ETT depth in adult patients.

This is a prospective, observational, pilot study in a convenience sample of adults recently intubated in the prehospital, medical floor, intensive care unit, or emergency department settings of an urban, teaching hospital. Two physician participants separately performed ballottement on each intubated subject and rated the ballottement as none, weak, or strong prior to assessment of appropriate depth using a chest radiograph (CXR). Results were compared for simple agreement and compared to the CXR to estimate accuracy.

Of 163 patients, 27 (17%) had an inappropriate ETT depth. Physician assessments of ballottement agreed in 79% of patients (95% CI = 72-85%). Chest radiograph assessment found the ETT in the "strong" ballottement group properly placed in 93%, as compared to 77% in the "weak", and 42% in the "none" groups. Combining "weak" and "strong" ballottement, the sensitivity was 96% (95% CI = 93-100%), specificity was 26% (95% CI = 9-43%), and accuracy was 85% (95% CI = 79-90%).

Manual cuff palpation is a simple and reproducible technique that is sensitive, but nonspecific, in identifying intubations of appropriate depth.