Endotracheal Tube Insertion Depth Research Articles

Leveraging artificial intelligence to identify high-risk patients for postoperative sore throat: An observational study.

Postoperative sore throat (POST) is a prevalent complication after general anesthesia and targeting high-risk patients helps in its prevention. This study developed and validated a machine learning model to predict POST. A total number of 834 patients who underwent general anesthesia with endotracheal intubation were included in this study. Data from a cohort of 685 patients was used for model development and validation, while a cohort of 149 patients served for external validation. The prediction performance of random forest (RF), neural network (NN), and extreme gradient boosting (XGBoost) models was compared using comprehensive performance metrics. The Local Interpretable Model-Agnostic Explanations (LIME) methods elucidated the best-performing model. POST incidences across training, validation, and testing cohorts were 41.7%, 38.4%, and 36.2%, respectively. Five predictors were age, sex, endotracheal tube cuff pressure, endotracheal tube insertion depth, and the time interval between extubation and the first drinking of water after extubation. After incorporating these variables, the NN model demonstrated superior generalization capabilities in predicting POST when compared to the XGBoost and RF models in external validation, achieving an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI 0.74-0.89) and a precision-recall curve (AUPRC) of 0.77 (95% CI 0.66-0.86). The model also showed good calibration and clinical usage values. The NN model outperforms the XGBoost and RF models in predicting POST, with potential applications in the healthcare industry for reducing the incidence of this common postoperative complication.

Flexible Endoscopy With Non-invasive Ventilation Enables Clinicians to Assess and Manage Infants With Severe Bronchopulmonary Dysplasia.

ObjectivesThe objectives of the study were to determine the efficacy of flexible endoscopy (FE) to assess the approachable aeroesophageal tract (AET) and subsequent changes in clinical management in infants with severe bronchopulmonary dysplasia (sBPD).MethodsThis retrospective study investigated sBPD infants who received FE measurement from 2011 to 2020. FE was supported with non-invasive ventilation (FE-NIV) of pharyngeal oxygen with nose closure and abdominal compression without any mask or laryngeal mask airway. Data on AET lesions, changes in subsequent management, and FE therapeutic interventions were collected and analyzed.ResultsForty-two infants were enrolled in the study. Two thin scopes (1.8- and 2.6-mm outer diameter) were used. FE analysis revealed 129 AET lesions in 38 (90.5%) infants. Twenty-eight infants (66.7%) had more than one lesion. Thirty-five (83.3%) infants had 111 airway lesions where bronchial granulations (28, 25.2%), tracheomalacia (18, 16.2%), and bronchomalacia (15, 13.5%) were the main complications. Eighteen esophageal lesions were found in 15 (35.7%) infants. No significant FE-NIV complications were observed. The FE findings resulted in changes in management in all 38 infants. Thirty-six (85.7%) infants underwent altered respiratory care with pressure titrations (29, 45.3%), shortened suction depth (17, 26.6%), immediate extubation (8, 12.5%), changed insertion depth of endotracheal tube (7, 10.9%) and tracheostomy tube (3, 4.7%). Twenty-one (50%) infants had 50 pharmacotherapy changes, including added steroids, anti-reflux medicine, antibiotics, and stopped antibiotics. Eighteen (42.8%) infants received 37 therapeutic FE-NIV procedures, including 14 balloon dilatations, 13 laser-plasty, and 10 stent implantations. Seven (16.7%) infants underwent surgeries for four tracheostomies and three fundoplications.ConclusionFlexible endoscopy with this non-invasive ventilation could be a safe and valuable technique for direct and dynamic visual measurement of AET, which is essential for subsequent medical decision making and management in infants with sBPD.

Development and internal validation of an equation using anthropometric measures to predict correct endotracheal tube insertion depth.

PurposeTo develop, internally validate, and assess the utility of implementing a regression model for determining endotracheal tube (ETT) insertion depth.Research methodsWe recorded height, weight, age, sex, ETT internal diameter (ID), lip marking, and tracheal position from the electronic record from a random subset of 2,000 intubated subjects obtained from 1 January 2009 to 5 May 2012. A multivariable linear regression model was constructed and validated by a nonparametric bootstrapping technique using unrestricted random sampling methods. A prospective pilot of subjects admitted to the pediatric intensive care unit requiring invasive mechanical ventilatory support was conducted from 7 January 2019 to 31 May 2019. Those with spinal and/or skeletal malformations, without a post-intubation chest-x-ray (CXR) order, or whose CXR quality impaired visualizing the carina and ETT tip, were excluded. The validated regression equation determined insertion depth. CXR following intubation determined ETT position. Demographic data were summarized. Two-tailed, one-sample binomial test of proportions assessed differences in the proportion of correct position by the equation.Main findingsFour hundred and seventy-seven subjects included in model construction yielded 10,000 independent samples for internal validation; 55% were female, and the mean age (SD) was 47 (63) months. Bias between bootstrap coefficients and refined model estimates were negligible (P < 0.01). Eleven subjects in the pilot were female (64%), mean age (SD) of 36.7 (38) months. Four protocol violations (36.4%) resulted in malposition. Subsequent repositioning per protocol resulted in 100% correct positioning (P = 0.01).ConclusionThe regression equation [0.8636 * (Ht. 0.6223)] facilitated correct ETT placement. A larger, diverse sample is required for external model validation.

Ideal Depth of Endotracheal Intubation at the Vocal Cord Level in Pediatric Patients Considering Racial Differences in Tracheal Length.

Numerous formulas that can predict endotracheal intubation depth at the corner of the mouth or the nasal wing of patients have been reported, even though the oral and nasal cavity anatomies differ among patients. Therefore, the purpose of this study was to derive a simple and reliable formula to predict the ideal endotracheal tube insertion depth at the vocal cord level in pediatric patients. The current study was conducted as a retrospective observational study, involving 425 and 335 cardiac pediatric patients in Germany and Japan, respectively, and aimed to determine a formula for predicting tracheal length and ideal depth of endotracheal intubation at the vocal cord level in pediatric patients. The distance between the vocal cords and the carina tracheae was defined as the tracheal length, and was measured on preoperative chest radiographs obtained in the supine position. The tracheal length in cardiac pediatric patients ranged from 6 to 10% of the body height in Germany and from 7 to 11% in Japan. This study revealed racial differences in the tracheal length, that is, in the ideal depth of endotracheal intubation at the vocal cord level. This study suggests that an adequate endotracheal intubation depth can be achieved by inserting endotracheal tubes at the vocal cord level with the minimum tracheal length of each racial group in pediatric patients, for example, 6% and 7% of the body height in Europeans and Asians, respectively. If the endotracheal tube inserted with this method appears to be shallow on chest radiographs, this does not represent an increased risk of accidental extubation, due to an excessively short intubation depth, because the minimum tracheal length for each racial group is considered. That is, it is not due to the endotracheal tube insertion length, but is likely due to the tracheal length of the patient, who has a relatively long tracheal length in the racial group.

Accuracy of predictive equations in guiding tracheal intubation depth in children: A prospective study.

Accurate insertion depth of endotracheal tube (ETT) in children has been predicted using the demographic variables, such as age, weight, and height. Middle finger length showed good correlation with ETT depth measurement in children aged 4-14years. The primary objective was to correlate the actual ETT insertion depth with the depth derived from middle finger length, age, weight, and height formulae in children aged 1-4years. The secondary objective was to find the most accurate formula for prediction of ETT insertion depth. This prospective parallel group study was done in 50 american society of anesthesiologists 1 or 2 children aged 1-4years undergoing elective surgery under general anesthesia. Children with difficult airway, finger anomalies, or syndromic associations were excluded. Age, weight, height, and middle finger length of all children were measured. Depth of orally inserted uncuffed ETT and tracheal length was measured by fiberoptic bronchoscopy. The actual ETT depth was correlated with the depth calculated from different formulae. The mean middle finger length was 4.42±0.50cm, age was 2.64±1.07years, weight was 12.28±2.84kg, and height was 82.89±16.23cm. The mean tracheal length was 6.42±0.96cm. The mean depth of ETT was actual depth (12.89±1.09cm), middle finger depth (13.23±1.53cm; p=.001; 95%CI 0.12-0.50), age-based depth 1(3.31±0.53cm; 95%CI 0.37-1.44; p=.001), weight-based depth (14.14±1.42cm; 95% CI 0.10-0.51; p=.004), and height-based depth (13.73±0.94cm; 95% CI 0.15-0.77; p=.004). Middle finger length and age-based formulae showed higher number of accurate placements (58% each). Weight- (74%) and height (64%)-derived formulae gave a higher number of distal ETT placements. Formulas based on the demographic variables and middle finger length showed good correlation with the actual ETT depth in children aged 1-4years. The percentage of accurate ETT depth placements was higher with middle finger length and age-based formulae.

Weight Is More Accurate than Gestational Age When Estimating the Optimal Endotracheal Tube Depth in Neonates.

Determining the optimal endotracheal tube (ETT) depth in neonates remains challenging for neonatologists. The guideline for optimal ETT depth is based on the patients’ weight or gestational age. However, there is a discrepancy in the suggested ETT depth between these two parameters. The aim of this retrospective study was to compare the recommended weight-based and age-based formulas for optimal ETT depth and obtain the optimal reference before intubation. Participants were assigned to group 1 if the recommended ETT insertion depth based on weight was concordant with the recommended depth based on gestational age, and to group 2 if the weight and age-based depth recommendations were discordant. After exclusion, 180 patients were included in the analysis. Results indicated that the predicted ETT depth suggested by age required more adjustment than by weight (p < 0.05). Furthermore, the required adjustment in the weight-based formula was smaller than the age-based formula (p < 0.05). Multivariate linear regression analysis revealed that weight was the key factor affecting the optimal depth (p < 0.001). These results imply that when there is a discrepancy in ETT depth between the weight-based and age-based recommendation, the weight-based one will be more accurate than the age-based one.

New Formula for Nasal Endotracheal Intubation in Extremely Low–Birth Weight Infants in the Emergency Transport Setting: The “Genoa Formula”

ObjectiveThe purpose of this study was to find a predictive equation for estimating the optimal nasal endotracheal tube insertion depth in extremely low–birth weight infants (ELBWs) requiring invasive ventilation in the critical care interfacility transport setting. MethodsWe retrospectively calculated the optimal tube insertion depth in a cohort of neonates ≤ 1,000 g born at our neonatal intensive care unit and nasally intubated within the first 24 hours of life from January 2019 to May 2020. ResultsA total of 75 ELBW infants were included, with a median gestational age of 26.6 weeks (range, 22.1-32.6 weeks) and a median birth weight of 780 g (range, 410-990 g). The linear regression of the estimated optimal endotracheal tube insertion depth showed a good correlation when plotted against weight (R2 = 0.491); thus, a new weight-based formula was obtained. ConclusionThe proposed weight-based formula (the “Genoa formula”) may help in predicting optimal insertion depths for nasal intubation in ELBW neonates, especially when a prompt radiologic confirmation of the tube position is not available, as during neonatal critical care transport.

Ideal endotracheal tube insertion depth in neonates with a birthweight less than 750g.

Appropriate management of the endotracheal tube (ETT) insertion depth is important. The depth calculated using Tochen's formula is overestimated in extremely-low- birthweight infants, particularly those with a birthweight <750g. Gestational age has been shown to be particularly useful in the Neonatal Resuscitation Program, 7th edition.5 However, a randomized trial for estimating the ETT insertion depth failed to show the advantage of using gestational age over birthweight.6 Therefore, we aimed to estimate the appropriate ETT insertion depth in neonates weighing <750g. This was a single-center, retrospective observational study including neonates weighing <750g who required intubation. The appropriate depth was determined by adjusting the distance between the actual ETT position and the area from the first to the second thoracic vertebra on the radiograph. Correlations between gestational age and physique were investigated using Pearson's correlation coefficient. We examined small-for- gestational-age (SGA) infants and non-SGA infants separately. Forty neonates were enrolled in this study. The mean gestational age and birthweight were 26.3weeks and 620g respectively. Twenty infants were SGA. The ETT position was deep in 35 of 40 cases, with the strongest correlation between weight and ETT insertion depth. The correlation with gestational age was not observed in this study. Our study showed that the ideal ETT insertion depth at birth correlates with birthweight in neonates weighing <750g. Therefore, determination by gestational age may not be feasible in populations with a high proportion of SGA infants.

12. Comparison of Weight with Nasal-tragus Length as a Guide to Endotracheal Tube Insertion Depth in the Neonates: A Prospective Observational Randomized Comparative Study

12. Comparison of Weight with Nasal-tragus Length as a Guide to Endotracheal Tube Insertion Depth in the Neonates: A Prospective Observational Randomized Comparative Study

Is Nasal Septum-Tragus Length Measurement Appropriate for Endotracheal Tube Intubation Depth in Neonates? A Randomized Controlled Study.

Endotracheal intubation is a frequent procedure performed in neonates with respiratory distress. Clinicians use different methods to estimate the intubation insertion depth, but, unfortunately, the improper insertion results are very high. In this study, we aimed to compare the two different methods (Tochen's formula = weight in kilograms + 6 cm; and nasal septum-tragus length [NTL] + 1 cm) used to determine the endotracheal tube (ETT) insertion depth. Infants who had intubation indications were enrolled in this study. The intubation tube was fixed using the Tochen formula (Tochen group) or the NTL + 1 cm formula (NTL group). After intubation, the chest radiograph was evaluated (above T1, proper place, and below T2). A total of 167 infants (22-42 weeks of gestational age) were included in the study. The proper tube placement rate in both groups was similar (32.4 vs. 30.4% for infants < 34 weeks of gestational age and 56.8 vs. 45.0% in infants > 34 weeks of gestational age). The ETT was frequently placed below T2 at a higher rate in infants with a gestational age of <34 weeks, especially in the NTL group (46% in the Tochen group and 60.7% in the NTL group). The NTL + 1 cm formula led to a higher rate of ETT placement below T2, especially in infants with a birth weight of <1,500 g. Therefore, more studies are needed to determine the optimal ETT insertion depth.

Comprehensive Overview of Pediatric Airway Management

Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines. This review contains 6 figures, 8 tables, and 77 references. Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

Comprehensive Overview of Pediatric Airway Management

Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines. This review contains 6 figures, 8 tables, and 77 references. Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

Comprehensive Overview of Pediatric Airway Management

Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines. This review contains 6 figures, 8 tables, and 77 references. Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

Randomised trial of estimating oral endotracheal tube insertion depth in newborns using suprasternal palpation of the tip or weight

BackgroundEndotracheal tube (ETT) tip position is determined on chest X-ray (CXR) and should lie between the upper border of the first thoracic vertebra (T1) and the lower border of second...

Novel Formula for Calculation of the Optimal Insertion Depth for Cuffed Endotracheal Tubes in Pediatric Major Surgery

Background: Accurate determination of the optimal insertion depth of a pediatric endotracheal tube (ETT) is quite important. The aim of this study was to create an easily available formula that can be used to determine the optimal insertion depth for a cuffed ETT even without depth marking with clear definitions of the upper and lower limits for the tip of ETT in the trachea in clinical practice. Methods: Eighty children under 12 years of age were enrolled. The depth marking of the cuffed ETT was placed at the vocal cords and both lungs were then auscultated using a stethoscope. The upper limit was radiographically defined as the position of the tip of the cuffed ETT being between the clavicles. The lower limit was defined as a distance of 5 mm above the carina. The relationship between the insertion depth and patient characteristics was analyzed to create a formula for optimal ETT insertion depth. Results: Sixty-nine ETTs were optimally placed in the trachea. There were good correlations between the optimal insertion depth of ETTs and patients characteristics (height (R = 0.92); BSA (R = 0.92); weight (R = 0.91); age (R = 0.88)). Using these patient characteristics, we created the following three formulas for calculation of the optimal insertion depth for pediatric cuffed ETTs: insertion depth (cm) = height (cm)/11 + 5.5, weight (kg)/3 + 9.5 or 11 + 3/4 × age (years). The rates of appropriate tube placement of both pediatric cuffed ETTs were 87.5% (Hi-Contour) and 85.0% (Microcuff). Conclusions: Our formula and graphs may be easy to determine the optimal insertion depth of cuffed ETT even without depth marking in clinical practice.

Optimal Insertion Depth for Endotracheal Tubes in Extremely Low-Birth-Weight Infants.

To determine the optimal endotracheal tube insertion depth in extremely low-birth-weight infants based on the association between endotracheal tube depth and gestational age, body weight, body length, and head and chest circumferences at birth. Retrospective chart review. Neonatal ICU at a medical center. Fifty-two hospitalized extremely low-birth-weight infants in our neonatal ICU. None. Data regarding gestational age, body weight, body length (crown-heel length), head and chest circumferences, and final endotracheal tube depth were retrieved from the medical records of 52 newborn infants weighing less than or equal to 1,000 g at birth (boys, 29; girls, 23). The mean gestational age was 25.1 (range, 22-32) weeks, and the mean body weight was 724.5 (range, 400-1,000) g. Of the endotracheal tubes used, 3%, 87%, and 10% of endotracheal tubes were of size 2.0, 2.5, and 3.0, respectively. Linear regression analysis revealed a significant association between endotracheal tube depth and gestational age, body weight, body length, head, and chest circumferences (p < 0.001). Body weight had the highest coefficient of determination (r = 0.497), followed by body length (0.458), with all other variables having values of less than 0.4. In extremely low-birth-weight infants, a linear association exists between endotracheal tube insertion depth and gestational age, body weight, body length, chest, and head circumferences at birth. Although body weight is the most accurate method for predicting endotracheal tube insertion depth, body length is also appropriate and is more favorable than body weight in delivery room resuscitation. Although no substitute for radiologic confirmation exists, a tape measure that can convert body length to endotracheal tube depth may be helpful.

Assessment of Carina Position Antenatally and Postnatally in Infants with Congenital Diaphragmatic Hernia

To determine whether endotracheal tube (ETT) insertion depth should be modified in infants with congenital diaphragmatic hernia (CDH) to reduce the risk of main-stem intubation. The distance from the thoracic inlet to the carina was measured antenatally by fetal magnetic resonance imaging (MRI) between 20-28 weeks' (early) and 30-34 weeks' (late) gestation in 30 infants with CDH and compared with 12 early and 36 late MRIs in control infants without CDH. Postnatal tube position was assessed by chest radiograph in the same 30 infants with CDH and compared with 20 control infants with postnatal birth depression. The carina position was displaced upward in fetuses and newborns with CDH. Distance from the thoracic inlet to the carina compared with controls was 1.04 ± 0.1 cm vs 1.42 ± 0.07 cm on early MRI (P < .05), 1.43 ± 0.14 cm vs 1.9 ± 0.04 cm on late MRI (P < .01), and 2.36 ± 0.07 cm vs 3.28 ± 0.05 cm on postnatal radiographs (P < .01). Adjusting the ETT depth by 1 cm resulted in a median distance of 1.27 cm from the tip of the ETT to the carina. Cephalad displacement of the carina in infants with CDH may predispose them to right main-stem intubation and subsequent development of pneumothorax. We speculate that modifying the ETT insertion depth to 5.5 cm + weight in newborns born at term may prevent pneumothoraces and improve outcomes for infants with CDH.

Randomised trial of estimating oral endotracheal tube insertion depth in newborns using weight or vocal cord guide

BackgroundWhen intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant’s weight....

Accuracy of the nasal-tragus length measurement for correct endotracheal tube placement in a cohort of neonatal resuscitation simulators.

Nasal-tragus length (NTL) estimates of endotracheal tube (ETT) depth are replacing weight-based estimates for endotracheal tube depth in neonates requiring endotracheal intubation. Existing neonatal simulators were designed before interest in using the NTL, and may lack fidelity in this measurement. The objective of this study is to evaluate the accuracy of the adjusted NTL formula and the Neonatal Resuscitation Program (NRP) gestational age/weight-based ETT depth chart in predicting proper endotracheal tube insertion depth in a cohort of neonatal simulators. The NTL and appropriate intubation depth to the mid-trachea were measured for 11 commonly used neonatal intubation simulators. The NTL+1 cm formula incorrectly estimates the mid-tracheal depth in 82% of simulators, and the weight-based chart incorrectly estimates depth in 75% of test simulators. Only one simulator experienced a mainstem intubation with ETT insertion to the depth predicted by the NTL+1 cm formula. The majority of neonatal resuscitation simulations lacked physical fidelity with regard to mid-tracheal ETT insertion depth. The NRP gestational age/weight-based chart outperformed the NTL+1 cm formula but still resulted in endotracheal tube misplacement in the majority of neonatal simulators. The majority of simulators had adequate functional fidelity using either method for ETT depth estimation.

Detection of Endotracheal Intubation by Insertion Depth of Endotracheal Tube, Bilateral Chest Auscultation, and Observation of Bilateral Chest Movement during Emergency Intubation: Prospective Observational Study

Detection of Endotracheal Intubation by Insertion Depth of Endotracheal Tube, Bilateral Chest Auscultation, and Observation of Bilateral Chest Movement during Emergency Intubation: Prospective Observational Study