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Am J Perinatol 2019; 36(14): 1498-1503
DOI: 10.1055/s-0039-1678531
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Weight-Based Guide Overestimates Endotracheal Tube Tip Position in Extremely Preterm Infants

Sujith S. Pereira 
1   Neonatal Unit, Aberdeen Maternity Hospital, Aberdeen, United Kingdom
2   Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine, London, United Kingdom
,
Edwin-Amalraj Raja
3   Division of Medical Statistics, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
,
Saulius Satas
1   Neonatal Unit, Aberdeen Maternity Hospital, Aberdeen, United Kingdom
› Author Affiliations Funding None.
Further Information

Publication History

25 July 2018

31 December 2018

Publication Date:
19 February 2019 (online)

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Abstract

Objective To evaluate the association between endotracheal tube (ETT) tip position and adverse pulmonary outcomes using chest X-ray (CXR) in extremely preterm infants in whom ETT insertion length was estimated using weight + 6 guide (adding 6 cms to the infant’s weight in kg).

Study Design CXRs of 85 infants performed in the first week were reviewed for right-sided atelectasis, air leaks, and uneven lung inflation. The first CXR was later reviewed to document the ETT tip. Regression analysis was performed to find the association between ETT tip position and adverse outcome after adjusting for other confounders.

Results Forty (46%) infants had ETT tip placement between the first and second thoracic vertebrae (optimal position) compared with 45 (53%) who had the ETT tip placement outside this range (suboptimal position). Infants with suboptimal ETT were ventilated for a longer period (6.1 vs. 15.9 days; p = 0.004). The odds of adverse outcomes was 11.6 (95% confidence interval: 3.03, 44.1) times higher among infants who did not have ETT at the optimal position compared with infants who had ETT at the optimal position.

Conclusion Weight + 6 guide is not recommended to estimate ETT insertion length in extremely preterm infants. Gestation-based guide may be more appropriate to estimate ETT insertion length in this group of infants.

Keywords

endotracheal tube - extremely preterm infants - pulmonary outcomes - chest X-ray
 

  • References

  • 1 Bajaj M, Natarajan G, Shankaran S. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Delivery room resuscitation and short-term outcomes in moderately preterm infants. J Pediatr 2018; 195: 33-38
    CrossrefPubMedGoogle Scholar
  • 2 Biniwale M, Wertheimer F. Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants. Resuscitation 2017; 116: 33-38
    CrossrefPubMedGoogle Scholar
  • 3 Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal intubation. Resuscitation 2008; 77 (03) 369-373
    CrossrefPubMedGoogle Scholar
  • 4 Mainie P, Carmichael A, McCullough S, Kempley ST. Endotracheal tube position in neonates requiring emergency interhospital transfer. Am J Perinatol 2006; 23 (02) 121-124
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Thayyil S, Nagakumar P, Gowers H, Sinha A. Optimal endotracheal tube tip position in extremely premature infants. Am J Perinatol 2008; 25 (01) 13-16
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Embleton ND, Deshpande SA, Scott D, Wright C, Milligan DW. Foot length, an accurate predictor of nasotracheal tube length in neonates. Arch Dis Child Fetal Neonatal Ed 2001; 85 (01) F60-F64
    CrossrefPubMedGoogle Scholar
  • 7 Whyte KL, Levin R, Powls A. Clinical audit: optimal positioning of endotracheal tubes in neonates. Scott Med J 2007; 52 (02) 25-27
    PubMedGoogle Scholar
  • 8 Tochen ML. Orotracheal intubation in the newborn infant: a method for determining depth of tube insertion. J Pediatr 1979; 95 (06) 1050-1051
    CrossrefPubMedGoogle Scholar
  • 9 Gill I, O'Donnell CP. Vocal cord guides on neonatal endotracheal tubes. Arch Dis Child Fetal Neonatal Ed 2014; 99 (04) F344
    CrossrefPubMedGoogle Scholar
  • 10 Saboo AR, Dutta S, Sodhi KS. Digital palpation of endotracheal tube tip as a method of confirming endotracheal tube position in neonates: an open-label, three-armed randomized controlled trial. Paediatr Anaesth 2013; 23 (10) 934-939
    CrossrefPubMedGoogle Scholar
  • 11 Tatwavedi D, Nesargi SV, Shankar N, Mathias P, Rao Pn S. Efficacy of modified Tochen's formula for optimum endotracheal tube placement in low birth weight neonates: an RCT. J Perinatol 2018; 38 (05) 512-516
    CrossrefPubMedGoogle Scholar
  • 12 Sakhuja P, Finelli M, Hawes J, Whyte H. Is it time to review guidelines for ETT positioning in the NICU? SCEPTIC-Survey of Challenges Encountered in Placement of Endotracheal Tubes in Canadian NICUs. Int J Pediatr 2016; 2016: 7283179
    PubMedGoogle Scholar
  • 13 Kempley S. Neonatal endotracheal intubation: the 7–8–9 rule. Arch Dis Child Educ Pract Ed 2009; 94 (01) 29
    PubMedGoogle Scholar
  • 14 Peterson J, Johnson N, Deakins K, Wilson-Costello D, Jelovsek JE, Chatburn R. Accuracy of the 7-8-9 rule for endotracheal tube placement in the neonate. J Perinatol 2006; 26 (06) 333-336
    CrossrefPubMedGoogle Scholar
  • 15 American Academy of Pediatrics and American Heart Association. Neonatal Resuscitation Textbook. 6th ed. (English version). Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2011
    Google Scholar
  • 16 Kattwinkel J, Perlman JM, Aziz K. , et al; American Heart Association. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010; 126 (05) e1400-e1413
    CrossrefPubMedGoogle Scholar
  • 17 Richmond S, Wyllie J. European Resuscitation Council Guidelines for Resuscitation 2010 Section 7. Resuscitation of babies at birth. Resuscitation 2010; 81 (10) 1389-1399
    CrossrefPubMedGoogle Scholar
  • 18 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
    CrossrefPubMedGoogle Scholar
  • 19 Firth D. Bias reduction of maximum likelihood estimates. Biometrika 1993; 80 (01) 27-38
    CrossrefPubMedGoogle Scholar
  • 20 Finn D, Kinoshita H, Livingstone V, Dempsey EM. Optimal line and tube placement in very preterm neonates: an audit of practice. Children (Basel) 2017; 4 (11) E99
    CrossrefPubMedGoogle Scholar
  • 21 Amarilyo G, Mimouni FB, Oren A, Tsyrkin S, Mandel D. Orotracheal tube insertion in extremely low birth weight infants. J Pediatr 2009; 154 (05) 764-765
    CrossrefPubMedGoogle Scholar
  • 22 Flinn AM, Travers CP, Laffan EE, O'Donnell CP. Estimating the endotracheal tube insertion depth in newborns using weight or gestation: a randomised trial. Neonatology 2015; 107 (03) 167-172
    CrossrefPubMedGoogle Scholar
  • 23 Sakhuja P, Whyte H. ETT tip positioning in neonatal resuscitation guidelines. Resuscitation 2016; 106: e23
    PubMedGoogle Scholar
  • 24 O'Shea JE, O'Gorman J, Gupta A. , et al. Orotracheal intubation in infants performed with a stylet versus without a stylet. Cochrane Database Syst Rev 2017; 6: CD011791
    PubMedGoogle Scholar
  • 25 O'Donnell CP, Kamlin CO, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics 2006; 117 (01) e16-e21
    CrossrefPubMedGoogle Scholar
  • 26 Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr 2005; 146 (05) 638-641
    CrossrefPubMedGoogle Scholar
  • 27 Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics 2003; 112 (6 Pt 1): 1242-1247
    CrossrefPubMedGoogle Scholar
  • 28 American Academy of Pediatrics and American Heart Association. Neonatal Resuscitation Program - Reference Chart. Neonatal Resuscitation Textbook. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2016
    Google Scholar
  • 29 Garg A, Sinha AK, Kempley ST. Improving endotracheal tube placement in neonates. Arch Dis Child Fetal Neonatal Ed 2018; 103 (04) F395
    CrossrefPubMedGoogle Scholar
  • 30 Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 2014; 42 (01) 169-178
    CrossrefPubMedGoogle Scholar
  • 31 O'Shea JE, Thio M, Kamlin CO. , et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics 2015; 136 (05) 912-919
    CrossrefPubMedGoogle Scholar