Prediction Of Endotracheal Tube Size Research Articles

The accuracy of the ultrasound measured transverse cricoid diameter and the epiphyseal transverse diameter of the distal radius in predicting the pediatric endotracheal tube size.

In everyday pediatric anesthesia practice, clinicians frequently exchange an already inserted endotracheal tube because of a leak or resistance causing significant morbidity. We investigated the accuracy of two ultrasound measurements; the transverse cricoid diameter and epiphyseal diameter of the distal radius in the prediction of endotracheal tube size that best fits in children compared to age-based formulas. One hundred children (1-6 years) who underwent elective surgery with endotracheal tube whether cuffed (n = 50) or uncuffed (n = 50) were enrolled. The primary endpoint was the agreement between the reference tube size for which its outer diameter was selected based on transverse cricoid diameter and the final best-fit-ETT. The Correlation and Bland Altman agreement tests were conducted between best-fit-ETT outer diameter and ultrasound-measured outer diameter, and between best-fit-ETT inner diameter and inner diameter calculated by age-based formulas. The agreement rate between transverse cricoid diameter-based endotracheal tube size and best-fit-ETT size was 88% in cuffed group compared to 90% in uncuffed group. A significant positive correlation was reported between the outer diameter of best-fit-ETT and the outer diameter measured by the two ultrasound methods. A lower degree of positive correlation was reported between the inner diameter of best-fit-ETT, and the inner diameter calculated by age-based formulas. Bland Altman's analysis showed agreement between best-fit-ETT outer diameter and epiphyseal diameter of the distal radius in both groups and with transverse cricoid diameter in the cuffed group, with no agreement with age-based formulas in either group. Both transverse cricoid diameter and epiphyseal diameter of the distal radius are reliable predictors of the size of best-fit-ETT pediatric endotracheal tube compared to age-based formulas. To save time and effort, we recommend the US measurement of the epiphyseal diameter of distal radius in the preoperative visit and documenting the predicted tube size with the preoperative assessments.

Prediction of endotracheal tube size in pediatric patients: Development and validation of machine learning models.

We aimed to construct and validate machine learning models for endotracheal tube (ETT) size prediction in pediatric patients. Data of 990 pediatric patients underwent endotracheal intubation were retrospectively collected between November 2019 and October 2021, and separated into cuffed and uncuffed endotracheal tube subgroups. Six machine learning algorithms, including support vector regression (SVR), logistic regression (LR), random forest (RF), gradient boosting tree (GBR), decision tree (DTR) and extreme gradient boosting tree (XGBR), were selected to construct and validate models using ten-fold cross validation in training set. The optimal models were selected, and the performance were compared with traditional predictive formulas and clinicians. Furthermore, additional data of 71 pediatric patients were collected to perform external validation. The optimal 7 uncuffed and 5 cuffed variables were screened out by feature selecting. The RF models had the best performance with minimizing prediction error for both uncuffed ETT size (MAE = 0.275 mm and RMSE = 0.349 mm) and cuffed ETT size (MAE = 0.243 mm and RMSE = 0.310 mm). The RF models were also superior in predicting power than formulas in both uncuffed and cuffed ETT size prediction. In addition, the RF models performed slightly better than senior clinicians, while they significantly outperformed junior clinicians. Based on SVR models, we proposed 3 novel linear formulas for uncuffed and cuffed ETT size respectively. We have developed machine learning models with excellent performance in predicting optimal ETT size in both cuffed and uncuffed endotracheal intubation in pediatric patients, which provides powerful decision support for clinicians to select proper ETT size. Novel formulas proposed based on machine learning models also have relatively better predictive performance. These models and formulas can serve as important clinical references for clinicians, especially for performers with rare experience or in remote areas.

Prediction of endotracheal tube size in the pediatric age group by ultrasound: A systematic review and meta-analysis.

Anatomical differences in the airway in pediatric patients, compared to adults pose many challenges during endotracheal intubation, such as selecting the proper sized endotracheal tube (ETT) during intubation. Our primary objective was to assess how accurate is ultrasound (US) co-relation in comparison to standard age-based formulas in pediatric patients. Meta-analysis was registered in PROSPERO 2020, CRD42020220041. Online literature available in PubMed, Cochrane, and Embase, Goggle scholar was searched from year 2000 till November 30, 2020, using relevant Mesh terms, ('airway US' OR (('airway'/exp OR airway) AND ('US'/exp OR US))) AND ('endotracheal intubation'/exp OR 'endotracheal intubation') AND ('pediatric'/exp OR pediatric)" to Predict endotracheal tube size/placement in pediatric age (neonate till 18 years) by the US. Bibliographic cross-references of selected publications were further manually screened. The full texts of each article were studied, once the abstract was found appropriate independently by two reviewers. A total of 48 papers published between 2010 and 2020 were identified as relevant and read in detail. Average numbers of patients were 86 and total numbers of patients were 1978. Most of the studies included pediatric patients posted for elective surgeries under general anesthesia and excluded emergency procedures, known laryngeal or tracheal pathology, high-risk patients, recent upper respiratory tract infections or allergy to ultrasound gel. A total of 18 independent correlations were analyzed. Final combined r value calculated from all the included articles was 0.824 (95% CI 0.677, 0.908) with a P < 0.00001 {strong co-relation (r > 0.80)}. Q statistic of 756.484, and I2 statistics of 97.53% showed a large degree of heterogeneity in the effect size across the studies. Use of US for upper airway in pediatric patients is an effective modality and can effectively predict endotracheal tube size estimations in comparison to standard age-based or height-based formulae in the pediatric age group. US is a non-invasive, cost-effective, portable, and reproducible technique as compared to CT and MRI. It also takes less time with increasing expertise and experience.

Prediction of Endotracheal Tube Size in Pediatric Population Using Ultrasonographic Subglottic Diameter and Age-Related Formulas: A Comparative Study.

Background:Choosing the correct Endotracheal tube (ETT) size is important in paediatric patients because an inappropriately large and small sized tube has its own disadvantages and chances of re-intubation with different size tube is high. The currently available modalities do not reflect the actual tracheal diameter for selection of endotracheal tube. Ultrasonography (USG) guided evaluation of transverse diameter at subglottic region may be helpful to estimate the proper size of ETT. We tested the hypothesis that Ultrasound guided subglottic diameter better predicts optimal ETT size than existing methods.Aims:To predict the appropriate size of ETT in pediatric patients to avoid multiple attempts of intubation and airway edema using simple noninvasive USG-guided methods.Settings and Design:Design: Prospective studySettings:Tertiary care hospital.Materials and Methods:Institutional ethical committee clearance no. BMCRI/PS/138/2020-21 was taken. Laryngoscopy and endotracheal intubation were done in 27 pediatric patients of age 2-15 years using a predetermined-sized ETT, estimated by ultrasonography. ETT size was considered optimal when the cuff leak test was negative. If there was resistance to ETT passage into the trachea, the tube was exchanged with one that was 0.5 mm smaller. If the cuff leak test was positive, then the ETT was exchanged for one with the 0.5-mm larger tube. The comparison was done between the size of ETT calculated by USG-guided subglottic diameter, age, height-related formulas, and clinical methods to look for accuracy of prediction for proper ETT size after cuff leak test.Statistical Analysis:The data collected were entered into Microsoft Excel and analyzed using SPSS version 22. IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Appropriate parametric and nonparametric tests were applied wherever necessary.Categorical data:Represented in the form of frequencies and proportions. Continuous data: Represented as mean and standard deviation. Paired sample test: Test to identify the mean difference between two quantitative variables. Kappa statistics: To measure the level of agreement.Results:A total of 27 children of age between 2 and 15 years were selected, out of which 15 were male and 12 were female. The accuracy of predicting appropriate ETT size is greater in ultrasound-guided subglottic diameter when compared to conventional clinical assessment and age- and height-related formula and almost the same accuracy as the clinical method.Conclusion:Ultrasound-guided subglottic diameter is an easy, effective, and noninvasive way of predicting accurate ETT size in the pediatric population.

Prediction of endotracheal tube size for pediatric patients from the length of the middle finger in comparison with standard age-based formula in South Indian population

Prediction of endotracheal tube size for pediatric patients from the length of the middle finger in comparison with standard age-based formula in South Indian population

Prediction of endotracheal tube size using a printed three-dimensional airway model in pediatric patients with congenital heart disease: a prospective, single-center, single-group study.

BackgroundTo determine the correct size of endotracheal tubes (ETTs) for endotracheal intubation of pediatric patients, new methods have been investigated. Although the three-dimensional (3D) printing technology has been successful in the field of surgery, there are not many studies in the field of anesthesia. The purpose of this study was to evaluate the accuracy of a 3D airway model for prediction of the correct ETT size, and compare the results with a conventional age-based formula in pediatric patients.MethodsThirty-five pediatric patients under six years of age who were scheduled for congenital heart surgery were enrolled. In the pre-anesthetic period, the patient’s computed tomography (CT) images were converted to Standard Triangle Language (STL) files using the 3D conversion program. A Fused Deposition Modelling (FDM) type 3D printer was used to print 3D airway models from the sub-glottis to the upper carina. ETT size was selected by inserting various sized cuffed-ETTs to a printed 3D airway model.ResultsThe 3D method selected the correct ETT size in 21 out of 35 pediatric patients (60%), whereas the age-based formula selected the correct ETT size in 9 patients (26%).ConclusionsPrediction of the correct size of ETTs using a printed 3D airway model demonstrated better results than the age-based formula. This suggests that the selection of ETT size using a printed 3D airway model may be feasible for helping minimize re-intubation attempts and complications in patients with congenital heart disease and/or those with an abnormal range of growth and development.

Learning curve of ultrasound measurement of subglottic diameter for endotracheal tube selection in pediatric patients.

Endotracheal tube size can be predicted according to ultrasound measurement of subglottic airway diameter. The learning curve for this method is not yet established. The aim was to evaluate the learning curve of anesthesiology residents in ultrasound measurement of subglottic airway diameter for prediction of endotracheal tube size using cumulative sum analysis. Sixteen anesthesiology residents measured transverse subglottic airway diameter in children undergoing general anesthesia with cuffed endotracheal intubation. Each resident performed 30 ultrasound examinations. Primary outcome was the successful prediction of endotracheal tube size according to ultrasound measurement. Cumulative sumanalysis was performed with acceptable and unacceptable failure rates set as 20 and 40%, respectively. Ten out of 16 residents (62.5%) were deemed successful as they were able to pass lower decision boundary, whereas six residents' CUSUM scores were between the decisions lines deeming them indeterminate. The overall success rate for determining the correct endotracheal tube size was 77.5%. Median number of attempts to cross lower decision boundary was 29 with minimum of 18 and maximum of 29 attempts among successful residents. Learning curves constructed with cumulative sumanalysis in this study showed that only 62.5% of residents were able to correctly predict cuffed endotracheal tube size with 80% success rate. Considerable variability in achieving competency necessitates objective follow-up of individual improvement.

Factors influencing the accuracy of ETT size prediction in children with CHD: a pilot study

Induction and intubation for pediatric patients with congenital heart defects (CHD) should be conducted with careful measures to avoid any complications due to anesthetic drugs. Proper endotracheal tube (ETT) size is essential to avoid reintubation. The aim of this study is to analyze factors affecting the accuracy of uncuffed ETT size prediction in paediatrics with CHD. This observational-analytic study included seventeen patients aged 0-8 years with CHD underwent general anesthesia with tracheal intubation. Subjects were classified as cyanotic or acyanotic heart disease. The ETT size was predicted by Cole’s formula. The accuracy of prediction was analyzed according to age, body weight, height and type of CHD. The prediction of ETT size was accurate in 53% of the subjects. The prediction was inaccurate in 63% of cyanotic subjects, while only 16.7% of acyanotic subjects. Univariate analysis for all variables showed there was no significant factor to affect the accuracy of ETT size prediction. The smallest p value was subject’s height. Height has a 69.8% affecting factor to predict the accurate ETT size. Thus, age, body weight, height and type of CHD are not statistically significant factors to affect the accuracy of ETT size prediction. But, height gives a better prediction to the accuracy of ETT size.

Prediction of endotracheal tube size in children by predicting subglottic diameter using ultrasonographic measurement versus traditional formulas.

Background:Paediatric airway assessment remains the most challenging task before the anaesthesiologists. Recent advancement in ultrasonography techniques should now allow for accurate and descriptive evaluation of paediatric airway. To compare calculated external diameters of the endotracheal tube from physical indices of traditional formulas and predetermined by ultrasound.Materials and Methods:100 subjects of either sex between 12-60 months of age, undergoing various elective surgeries under general anaesthesia requiring endotracheal intubation were enrolled in the study. The transverse diameter was measured at the level of cricoids cartilage by ultrasonography. The tracheal tube was considered best fit if air leak was satisfactory at 15-20 cm H2O of airway pressure. The obtained values were compared with the values of endotracheal tube size calculated by various age, height, weight based formulas and diameter of right and left little finger. The correlation of size of Endotracheal tube by different modalities was done and Pearson's correlation coefficient was obtained.Results:According to Pearson's correlation there was a moderate correlation of best fit Endotracheal tube with endotracheal tube size by age based formula (r = 0.743), body length based formula (r = 0.683), right little finger based formula (r = 0.587), left little finger based formula (r = 0.587) and multivariate formula (r = 0.741). There was a strong correlation with ultrasonography (r = 0.943).Conclusion:Ultrasonography is a reliable method of estimation of subglottic diameter and for prediction of endotracheal tube size in children.

Prediction of endotracheal tube size for pediatric patients from the epiphysis diameter of radius.

BackgroundUsing a too big or a too small size of an endotracheal tube in pediatric patients would result in tracheal injury or insufficient ventilation. Determining the appropriate endotracheal tube size is important because using an inappropriate size can cause complications. This study was performed to predict the appropriate endotracheal tube size by measuring the transverse diameter of the epiphysis of the distal radius under the assumption that the growth rates of cartilages in the entire body are close to each other.MethodsFifty-eight children aged 3 to 10 years who required general anesthesia were intubated with an uncuffed endotracheal tube. The tube size was considered to be appropriate when leaks occurred at inspiratory peak pressures between 10 to 25 mmHg. The transverse diameters of the epiphysis were measured with an ultra-sonogram at the distal radius and the proximal phalanx of the third finger and the fifth finger. Correlations and prediction probabilities of measurements were evaluated. The number needed to harm (NNH), which indicates the number of patients who need to be intubated for one patient who needs tube exchange, was investigated.ResultsThe Spearman's correlation coefficient between the endotracheal tube size and the epiphysis of the distal radius was 0.814, which was the biggest coefficient. For epiphysis of the proximal phalanx of the third finger and the fifth finger, the correlation coefficient was 0.704 and 0.701, respectively. If the Cole's formula was applied for selection of the tube size, the NNH would be 7.ConclusionsThe appropriate endotracheal tube size could be predicted by means of the epiphyseal transverse diameter of the distal radius rather than the circumference measurements of the phalanx.

Predicting Endotracheal Tube Size by Length in Newborns

The objective of this study was to determine the relationship of length to endotracheal tube (ETT) size in newborns and to use this relationship to develop a tool for predicting ETT size. The study, a prospective derivation, and validation of a predictive model, took place in the neonatal intensive care units (NICUs) in two urban teaching hospitals. Subjects included: ETT derivation set − 39 intubated neonates admitted to the NICU; Validation set − 69 intubated newborns from the same NICU. Leak percentages were measured in intubated neonates where the actual ETT size did not correlate with the tape-determined ETT size. Interventions were length, weight, and leak measurements. A prototype tape was developed using the derivation set and published anthropometric studies. The accuracy of the tape was validated on a separate set of newborns. The average relative difference between tape-predicted weight and actual weight was 9.5% (confidence interval [CI] = 8.3–10.6%) and was evenly distributed throughout all the weight groups. The tape predicted actual ETT size in 96% of cases (CI 86.3–99.5%) and was correct within 1 tube size (1/2 mm) in 100% (CI 94.8–100%). The only error in prediction of ETT size was in underestimation. Length-based weight estimations were tested on 100 subjects and predicted actual weight within 20% in 94% of cases. We concluded that length is an accurate predictor of ETT size and weight in term and preterm newborns and may be useful in situations in which weights are unobtainable, such as emergency resuscitation.