Ideal Placement for Endotracheal Intubation in Newborn Infants

ABSTRACT

PURPOSE: A malpositioned endotracheal tube poses a serious threat to the intubated patient. After intubation in newborn infants, the position of the endotracheal tube must be checked by a chest radiograph to ensure a minimum number of complications. The most commonly used reference point for placement is the medial ends of the clavicles, but it is known that the position of clavicles on a chest radiograph can be variable. The purpose of this study was to evaluate whether e body of the first thoracic vertebra (Tl) can be used as the standard reference point for endotracheal intubation instead of the clavicles because its fixed position on the chest radiographs. METHODS: Eighty-one radiographs of newborn who were admitted in NICU during the period from January 1, 1998 to December 31, 1998 at Kangdong Sacred Heart Hospital, Hallym University were reviewed prospectively and the following informations were recorded ( I ) positions of the clavicles and the carina in relation to the cervical or thoracic vertebra, or intervertebral disc space, and ( ii ) the distances in cm using a ruler on the films, from the carina to the clavicles and Tl. RESULTS: The carina overlay from T2-3 to T5, most commonly at T3 to T4 (74.1%) although the clavicles are placed from C3-4 to T1-2, most commonly at C6 to C7 (62.9%). On 74 (91.4%) examinations the clavicles lay above the Tl. The distance in centimeters from the carina to the clavicles and Tl increases in length as gestational age, birth weight, and height increases. Analysis of variance shows that the position of the clavicles was determined with significantly higher variation than Tl (F=6.92 vs F=3.80, P<0.01). CONCLUSION: Because the clinical sign we describe are unreliable for detecting endotracheal intubation, chest radiographs at the bedside should be obtained routinely immediately after intubation and daily thereafter to determine the position of the tube. In neonatal period, the tip of endotracheal tube should be placed at Tl on chest radiograph, and its use would obviate the need to measure the distance from carina.