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Published on: January 17, 2011
Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct
Eric A Harris1, Kristopher L Arheart, Donald H Penning
1Department of Anesthesiology, University of Miami, Miller school of Medicine, Miami, Florida, USA. eharris2@med.miami.edu
Insights
Fluoroscopy is a valuable tool for confirming endotracheal tube (ETT) placement in pediatric surgery, reducing malposition rates. This technique ensures optimal ventilation and patient safety during procedures.
Area of Science:
- Pediatric Anesthesiology
- Medical Imaging
- Surgical Safety
Background:
- Radiographic confirmation of endotracheal tube (ETT) placement is standard in ICUs but underutilized during surgery.
- Portable fluoroscopy units are often available in operating rooms, presenting an opportunity for enhanced intraoperative monitoring.
- Clinical examination alone may not reliably confirm correct ETT positioning.
Purpose of the Study:
- To evaluate the utility of fluoroscopy in identifying endotracheal tube malposition in pediatric surgical patients.
- To determine the incidence of ETT malposition (too shallow or too deep) in this population.
- To assess the effectiveness of fluoroscopy-guided adjustments for ETT placement.
Main Methods:
- Retrospective analysis of chest radiographs from 257 pediatric patients (12 days to 12 years) undergoing 446 procedures.
- Assessment of ETT position relative to the clavicular border and carina.
- Logistic regression analysis to determine the incidence of malposition.
Main Results:
- Eighteen percent of initial ETT placements were incorrect, contradicting clinical assessments.
- Malposition incidence was highest (35%) in infants under one year, decreasing with age but remaining significant.
- Fluoroscopy-guided repositioning was successful in 95% of cases, with the remainder requiring continuous fluoroscopic guidance.
Conclusions:
- Fluoroscopy is a safe and effective method for verifying endotracheal tube placement in pediatric surgery.
- Its availability in the operating room can significantly improve patient safety by ensuring correct ETT positioning.
- Routine use of fluoroscopy can reduce the incidence of potentially harmful ETT malpositions.
Purpose:
To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population.
Methods:
Chest radiographs from 257 children (age 12 days-12 yr), who presented for a total of 446 individual procedures in the fluoroscopy suite, were studied to determine the incidence of ETTs placed too shallow (above the inferior clavicular border) or too deep (at or below the carina). A logistic regression with outcomes of correct and incorrect was used to analyze the data points.
Results:
Eighteen percent of all the radiographs showed initial improper ETT placement, despite clinical evidence suggesting the contrary. The peak incidence of malposition, which occurred in patients under one year old, reached 35%. Incidence decreased with advancing age, but remained over 10% until the age of ten. A second attempt at positioning the tube, based on information from the chest radiograph, was successful in 95% of the cases. The remaining 5% required placement of the ETT under continuous fluoroscopic guidance.
Conclusion:
Fluoroscopy, when readily available in the operating room, is a safe and useful technique to ensure proper ETT placement among the pediatric population.
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