The intubation depth marker: the confusion of the black line (original) (raw)
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Tracheal palpation to assess endotracheal tube depth: an exploratory study
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2013
Purpose Correct placement of the endotracheal tube (ETT) occurs when the distal tip is in mid-trachea. This study compares two techniques used to place the ETT at the correct depth during intubation: tracheal palpation vs placement at a fixed depth at the patient's teeth. Methods With approval of the Research Ethics Board, we recruited American Society of Anesthesiologists physical status I-II patients scheduled for elective surgery with tracheal intubation. Clinicians performing the tracheal intubations were asked to ''advance the tube slowly once the tip is through the cords''. An investigator palpated the patient's trachea with three fingers spread over the trachea from the larynx to the sternal notch. When the ETT tip was felt in the sternal notch, the ETT was immobilized and its position was determined by fibreoptic bronchoscopy. The position of the ETT tip was compared with our hospital standard, which is a depth at the incisors or gums of 23 cm for men and 21 cm for women. The primary outcome was the incidence of correct placement. Correct placement of the ETT was defined as a tip [ 2.5 cm from the carina and [ 3.5 cm below the vocal cords. Results Movement of the ETT tip was readily palpable in 77 of 92 patients studied, and bronchoscopy was performed in 85 patients. Placement by tracheal palpation resulted in
A clinical sign to predict difficult tracheal intubation; a prospective study
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 1985
It has been suggested that the size of the base of the tongue is an important factor determining the degree of difficulty of direct laryngoscopy. A relatively simple grading system which involves preoperative ability to visualize the faucial pillars, soft palate and base of uvula was designed as a means of predicting the degree of difficulty in laryngeal exposure. The system was evaluated in 210 patients. The degree of difficulty in visualizing these three structures was an accurate predictor of difficulty with direct laryngoscopy (p < 0,001). Il a été suggéré que la grosseur de la base de la langue est un facteur important dans la détermination du degré de difficulté de la laryngoscopie directe. Un système relativement simple de classification impliquant la capacité pré-opératoire de visualiser les piliers du voile du palais, le voile du palais et la base de la luette a été conçu afin de prédire le degré de la difficulté d’ exposition du larynx. Ce système a été évalué chez 210 patients. On a trouvé que le degré de difficulté encourue lors de la visualisation de ces trois structures était un moyen précis pour prédire la difficulté de la laryngoscopie directe (p < 0.001).
The intubating LMA: a comparison of insertion techniques with conventional tracheal tubes
Canadian Journal of Anesthesia/ …, 2000
Purpose: To compare the performance of the intubating laryngeal mask airway (ILMA) in assisting blind tracheal intubation with conventional tracheal tubes of different curvatures and the frequency of possible associated complications. Methods: After informed consent, 240 ASA I-II adults undergoing elective surgery participated in a randomized, single blind clinical trial to receive blind trachea intubation via ILMA with a conventional tracheal tube curved with normal (Normal group) or reversed (Reverse group) direction. More than three attempts at intubation was regarded as failure. The lowest oxygen saturation during intubation was recorded and postintubation sore throat and hoarseness were evaluated with verbal analog scales. Results: The overall success rates of intubation with Normal and Reverse groups were not different (96.7% and 94.2% respectively). Successful intubation at the first attempt was higher in the Reverse group than in the Normal group (86.7% vs 75.0%, P=0.033). The incidence of sore throat was higher in the Normal group than in the Reverse group (19.2% vs 9.2% respectively, P =0.042). Conclusions: Blind trachea intubation via an ILMA with the conventional curved tracheal tube is feasible and highly successful. Reverse curve direction is preferable at the first attempt of intubation for its higher success rate and lower incidence of complications. Objectif : Comparer le fonctionnement du masque laryngé d'intubation (MLI) utilisé avec des tubes endotrachéaux de différentes courbures, pour faciliter l'intubation endotrachéale à l'aveugle, et la fréquence de complications possibles. Méthode : Ayant donné leur consentement éclairé, 240 adultes d'état physique ASA I-II devant subir une intervention planifiée ont participé à un essai clinique randomisé et à l'insu. L'intubation, à l'aveugle avec le MLI et un tube endotrachéal de courbure habituelle (groupe normal) ou par insertion inversée (groupe inversé), était notée comme un échec si elle exigeait plus de trois essais. On a enregistré la plus faible saturation en oxygène pendant l'intubation et évalué, selon une échelle verbale analogique, le mal de gorge et la raucité de la voix qui ont pu suivre l'intubation. Résultats : Le taux de succès de l'intubation n'a pas présenté de différence intergroupe significative (96,7 % et 94,2 % respectivement). Une intubation réussie au premier essai a été plus fréquente dans le groupe inversé que dans le groupe normal (86,7 % vs 75,0 %, P=0,033). L'incidence de mal de gorge a été plus élevée dans le groupe normal que dans le groupe inversé (19,2 % vs 9,2 % respectivement, P =0,042). Conclusion : L'intubation endotrachéale à l'aveugle avec un MLI et un tube endotrachéal de courbure habituelle est possible et fréquemment réussie. L'insertion par inversion de la courbure, préférable au premier essai d'intubation, présente un meilleur taux de réussite et moins de complications.
Istanbul Bilim University Florence Nightingale Journal of Medicine, 2019
Objectives: The aim of this study was to compare the sensitivity and specificity of the conventional methods with the gold standard method, capnography for detection of endotracheal tube (ETT) intubation, and the reliability of these conventional methods when the capnometer device is unavailable. Patients and methods: In this prospective cross-sectional study, patients were chosen according to inclusion criteria. The tube's passing through the vocal cords, blurring of ETT, hearing bilateral and equal sounds on lung auscultation, not hearing sounds on stomach auscultation, and observing chest expansion were the conventional methods used for confirmation of the ETT position. Results: A total of 84 patients who met inclusion criteria were included in the study. Outcomes of 96 intubations were evaluated. For confirmation of ETT position, sensitivity of the tube's passing through the vocal cords was 93%, specificity was 100%, positive predictive value (PPV) was 100%, and negative predictive value (NPV) was 67%. Sensitivity of lung auscultation was 100%, specificity was 83%, PPV was 98%, and NPV was 100%. Sensitivity of stomach auscultation was 90%, specificity was 100%, PPV was 100%, and NPV was 45%. When lung and stomach auscultation were evaluated together, sensitivity, specificity, PPV, and NPV were 100%. Conclusion: We believe that the tube's passing through the vocal cords, hearing bilateral and equal sounds on lung auscultation, and hearing no sounds on stomach auscultation could be used for confirming ETT position in the absence of capnography however the combined use of these methods is more reliable and effective.
Assessment of Endotracheal Tube Position After Oral Intubation in Neonates
Aim: Endotracheal intubation is a common procedure in the delivery room and neonatal intensive care unit. We aimed to determine the accuracy of this method of endotracheal tube (ETT) placement in our neonatal cohort. Materials and Methods: Data on infants requiring oral intubation were reviewed retrospectively. The initial ETT depth of insertion had been calculated using the Tochen 7-8-9 rule. The initial depth was compared to the mid-tracheal region. The differences between the initial and ideal depth was calculated and divided by the mid-tracheal distance. Infants were grouped according to their weights as ≤1000 g, 1001 to 2000 g, 2001 to 3000 g and ≥3001 g. Results: We evaluated ETT placement in 160 neonates. The mean gestational age was 32.2±4.4 weeks (23 to 41 weeks) and the mean weight was 1989±829 g (560 to 3800 g). The mean range of the difference between the initial depth and ideal depth divided by mid-tracheal distance was 0.39±0.04, 0.35±0.04, 0.46±0.05, and 0.23±0.04 in infants weighing ≤1000 g, 1001 to 2000 g, 2001 to 3000 g and ≥3001 g respectively (p=0.025). The differences between the 2001-3000 g group and the 1001-2000, also the 2001-3000 g group and the ≥3001 g group were statistically significant (p<0.05). Conclusion: The 7-8-9 rule should be used to assess ETT length in neonates, especially in those weighing more than 3 kg. As this rule has low accuracy for extremely low birth weight neonates, its reliability may not be high for neonates weighing less than 3 kg in weight. Keywords: Endotracheal intubation, neonates, Tochen’s rule, resuscitation, position of the tube
The assessment of three methods to verify tracheal tube placement in the emergency setting
Resuscitation, 2003
We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO 2 ) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO 2 monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one falsepositive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n 0/56), auscultation, the ETCO 2 , and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P B/0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n 0/81), auscultation, the ETCO 2 , and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P B/0.05 vs. EDD and ETCO 2 ). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO 2 monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO 2 or the EDD are not uncommon, and clinical methods are superior to the use of these devices. # Palavras chave: Abordagem da via aérea; Aparelho de detecção esofágica; Dió xido de Carbono no fim da expiração; Entubação traqueal; Departamento de emergência * Corresponding author. Tel.: '/91-82-257-5585. Resuscitation 56 (2003) 153 Á/157 www.elsevier.com/locate/resuscitation 0300-9572/02/$ -see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 -9 5 7 2 ( 0 2 ) 0 0 3 4 5 -3
Anesthesiology, 2001
Background: The design of an endotracheal tube has been shown to influence the passage of the tube through the glottis during fiberoptic intubation. Difficulty in passing the endotracheal tube can occur if the aryepiglottic folds obstruct the passage of the bevel. The relevant aspects of endotracheal tube design include the shape of the bevel, the material used by the manufacturer, and the ability of the tube to conform to the shape of the fiberscope. The aim of the current study was to compare the ease of passage through the glottis of two different tubes. One tube was a wire reinforced polyvinyl chloride tube with a standard bevel and the other was a newly designed tube with a bevel of different shape and made of silicone rubber. The new design is for use with the a commerical intubating laryngeal mask. Methods: The authors studied a population of 30 patients who received a standard anesthetic. In all cases, oral fiberoptic intubation was attempted. Anesthetic was administered to each patient using both tubes, and before the study the order of the tubes was randomized. The difficulty in passing the tube was assessed by a blinded observer and graded using a three-point scale (grade 1: no difficulty passing the tube; grade 2: obstruction to passing the tube relieved by withdrawal and a 90°anticlockwise rotation; grade 3: obstruction necessitating more than one manipulation or external laryngeal manipulation). Results: In 27 patients, no difficulty was shown by use of the silicone-tipped tube. In only three patients was there difficulty that necessitated a 90°anticlockwise twist. With the wire-reinforced tube, no difficulty was experienced on 14 occasions. Grade 1 difficulty was experienced eight times and difficulty necessitating more than one maneuver, head movement, or external laryngeal manipulation was seen on eight occasions. Statistical significance was achieved at P ؍ 0.0002 (Wilcoxon signed rank test). Conclusions: The authors conclude that the use of the silicone-tipped tube with the new bevel design may provide an advantage in the clinical situation of fiberoptic intubation.
Resuscitation, 2011
Objectives: This study aimed to assess the diagnostic accuracy and timeliness of using tracheal ultrasound to examine endotracheal tube placement during emergency intubation. Methods: This was a prospective, observational study, conducted at the emergency department of a national university teaching hospital. Patients received emergency intubation because of impending respiratory failure, cardiac arrest, or severe trauma. The tracheal rapid ultrasound exam (T.R.U.E.) was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the concordance between the T.R.U.E. and the capnography. Results: A total of 112 patients were included in the analysis, and 17 (15.2%) had esophageal intubations. The overall accuracy of the T.R.U.E. was 98.2% (95% confidence interval [CI]: 93.7-99.5%). The kappa (Ä) value was 0.93 (95% CI: 0.84-1.00), indicating a high degree of agreement between the T.R.U.E. and capnography. The sensitivity, specificity, positive predictive value, and negative predictive value of the T.R.U.E. were 98.9% (95% CI: 94.3-99.8%), 94.1% (95% CI: 73.0-99.0%), 98.9% (95% CI: 94.3-99.8%) and 94.1% (95% CI: 73.0-99.0%). The median operating time of the T.R.U.E. was 9.0 s (interquartile range [IQR]: 6.0, 14.0).