TOPIC: Respiratory Care
TYPE: Original Investigations
PURPOSE: Several guidelines and formula for endotracheal tube depth insertion are being studied and used. These suggested formulas in computation for the endotracheal tube (ETT) size and depth are based on age, weight and height of those with normal growth and mostly of the Western population. These may not be applicable for those children with growth impairment in patients with cardiac diseases. Investigation of the incidence of inappropriate ETT size and ETT malposition is important to lessen pulmonary complications in these population.
METHODS: This is a cross-sectional analytical study approved by the Institutional Review Board of the Philippine Heart Center. Review of charts of pediatric patients, neonates up to 18 years of age with heart disease, who has undergone endotracheal intubation between April 1, 2017 and December 31, 2019 was done. Age, gender, nutritional status, type of heart disease, setting of intubation, formula in computing for the ETT depth, and complications were all obtained from the charts of the patient. The actual ETT placement was compared with the computed ETT depth to identify which guideline specific formula was used. ETT placement, measured in centimeters, seen in chest radiograph taken in neutral position right after intubation was also obtained from the record of the patients. The chest radiographs were evaluated by a single identified radiologist to prevent inter-reader variation.
RESULTS: A total of 99 patients with heart disease who underwent endotracheal intubation were included with age ranging from 4 days to 18 years and mean age of 87.71 months (±14.04). There is male preponderance (60.6%). From the review of the post-intubation chest radiographs, 51.52% endotracheal tubes were in place and 48.48% were misplaced. The presence of malnutrition was not a significant factor (p=0.52). However, from the different types of malnutrition, severe stunting (p=0.021) was a factor in the occurrence of malpositioned ETT. Patients with severe stunting, were 3.23 times more likely to have malpositioned ETT as compared to those with normal growth and to those with stunting. In the multivariate analysis, the use of guideline-specified formula was noted to be a significant factor in decreasing the likelihood of malpositioned ETT. Neonates intubated using the Neonatal Resuscitation Program (NRP) formula were 96.87% less likely to have malpositioned endotracheal tube. Furthermore, the NRP guideline was also utilized in infants up to 2 months old who weighed less than 4 kilograms. For those belonging to older age group, Internal Diameter (ID) estimation and Pediatric Advanced Life Support (PALS) formula were 75.33% and 70.88% less likely to have malpositioned ETT, respectively. Wheezing or bronchospasm was the most common complication followed by atelectasis of the left lung.
CONCLUSIONS: There are several guidelines and recommendations in proper endotracheal tube insertion a mediical provider may choose and use; however, important factors and characteristics of the individual patient, such as his or her nutritional status should be taken into consideration.
CLINICAL IMPLICATIONS: This important and life-saving emergency procedure should be further studied in the pediatric population with different growth patterns to decrease incidence of malpositoning and further pulmonary complications.
DISCLOSURES: No relevant relationships by Karenne Somera, source=Web Response
© 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.