Review articleConfirmation of correct tracheal tube placement in newborn infants☆
Section snippets
Background
Tracheal intubation remains a common procedure in the neonatal intensive care unit (NICU) and the delivery room (DR).1, 2, 3, 4, 5 The insertion of a tube into the trachea to inflate the lungs of newborn infants has been routinely practiced for almost a century. James Blundell described digital intubation in 1834 as “Inserting a tracheal catheter guided along the fingers, through which the accoucheur could inflate the infant's lungs with his own breath”.6 However, it took almost a century until
Search strategy
We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms “Infant, Newborn”, “Tracheal intubation”, “Resuscitation”, “Clinical signs”, “Radiography”, “Respiratory Function Tests”, “Laryngoscopy”, “Bronchoscopy”, and “Ultrasonography”. All languages were included. The full search strategies for PubMed, EMBASE and PubMed Central are detailed in Appendix 1.
Tracheal vs. esophageal tube placement
Various techniques have been studied to determine correct tube placement including (i) clinical signs, (ii) capnography, (iii) respiratory function, (iv) fiber optic techniques, and (v) video laryngoscopy, which are described in detail below.
Correct tube position within the trachea
Various techniques have been studied to determine optimal position within the trachea including (i) chest radiograph, (ii) measurement of tube length based on parameters of body size or gestational age, (iii) external digital tracheal palpation, (iv) fiber optic techniques, and (v) ultrasonography.
Duration of the procedure
Guidelines of the Neonatal Resuscitation Program developed by the American Academy of Pediatrics recommend that the intubation procedure is completed within 30 seconds.17 Two observational studies reported the times to intubate preterm infants in the DR using a laryngoscope.2, 63 Overall, 50–60% of intubation attempts were successful, with the majority occurring within 30 seconds.2, 63 Interestingly, two studies reported that digital intubation was significantly faster compared to intubation
Conclusions
Currently chest radiography remains the accepted standard test to confirm tube position. An increase in heart rate is the best indication of effective ventilation. Exhaled CO2 may give misleading, false negative results and readings should be interpreted in conjunction with clinical signs. Respiratory function monitors, video laryngoscopes, fiber optic devices and ultrasound to confirm tube position are promising methods but require evidence from clinical trials before recommendations can be
Conflict of interest statement
None.
Author's contribution
Dr. Georg M. Schmölzer conceptualized and designed the study, carried out the initial literature search and analysis of available literature, drafted the initial manuscript, and approved the final manuscript as submitted.
Dr. Megan O’Reilly carried out the initial literature search and analysis of available literature, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Dr. Peter G. Davis performed a literature search and analysis of available literature, reviewed
Acknowledgements
We acknowledge the support of the European Respiratory Society, Fellowship LTRF fellowship no. 15-2011 for Charles C Roehr.
GMS is a supported by a Banting Postdoctoral Fellowship, Canadian Institute of Health Research and an Alberta Innovate – Health Solution Clinical Fellowship. PGD is supported by an Australian National Health and Medical Research Council Practitioner and Principal Research Fellowship, respectively. PGD holds an Australian National Health and Medical Research Council Program
References (71)
- et al.
Neonatal intubation: success of pediatric trainees
J Pediatr
(2005) - et al.
Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation
Resuscitation
(2011) - et al.
Asphyxia neonatorum: its treatment by tracheal intubation
Lancet
(1935) - et al.
Endotracheal tube position in the infant
J Pediatr
(1971) - et al.
Orotracheal tube insertion in extremely low birth weight infants
J Pediatr
(2009) - et al.
Assessment of chest rise during mask ventilation of preterm infants in the delivery room
Resuscitation
(2011) Measurement of inspired and expired oxygen and carbon dioxide
Br J Anaesth
(1969)- et al.
End-tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest
Am J Emerg Med
(1996) - et al.
Colorimetric end-tidal carbon dioxide detectors in the delivery room: strengths and limitations. A case report
J Pediatr
(2005) - et al.
Assessment of gas flow waves for endotracheal tube placement in an ovine model of neonatal resuscitation
Resuscitation
(2010)
The use of a new ultra-thin fiberoptic bronchoscope to determine endotracheal tube position in the sick newborn infant
Chest
Flexible fiberoptic bronchoscopy: techniques and review of 100 bronchoscopies
Chest
Estimation of nasotracheal tube length in infants and children
Br J Anaesth
Orotracheal intubation in the newborn infant: a method for determining depth of tube insertion
J Pediatr
Endotracheal tube length for neonatal intubation
Resuscitation
A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates
Resuscitation
Duration of intubation attempts during neonatal resuscitation
J Pediatr
Neonatal laryngoscope intubation and the digital method: a randomized controlled trial
J Pediatr
Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects
Pediatrics
The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit
Pediatr Pulmonol
The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns
J Perinatol
Dr James Blundell (1790–1878) and neonatal resuscitation
Arch Dis Child
Treatment of asphyxia in the new-born. Preliminary report of the practical application of modern scientific methods
J Am Med Assoc
An anaesthetist's contribution to the resuscitation of the newborn
J Obstet Gynaecol Br Emp
Resuscitation of the newborn
Br Med J
Routine chest radiographs in pediatric intensive care: a prospective study
Pediatrics
A new system for location of endotracheal tube in preterm and term neonates
Pediatrics
Endotracheal tube placement in infants determined by suprasternal palpation: a new technique
Pediatrics
Proficiency of pediatric residents in performing neonatal endotracheal intubation
Pediatrics
Part 15: Neonatal Resuscitation: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
Circulation
Esophageal intubation: a review of detection techniques
Anesth Analg
Use of capnography in the delivery room for assessment of endotracheal tube placement
J Perinatol
Heart rate changes during resuscitation of newly born infants
Arch Dis Child Fetal Neonatal Ed
Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room
Arch Dis Child Fetal Neonatal Ed
The value of carbon dioxide monitoring during anaesthesia
Anaesthesia
Cited by (50)
Neonatal monitoring during delivery room emergencies
2019, Seminars in Fetal and Neonatal MedicineCitation Excerpt :Colorimetric detection of carbon dioxide (CO2) in the expired gas is one of the methods commonly used to confirm endotracheal tube placement. This test is dependent on adequate pulmonary blood flow for CO2 to be exhaled, and may incorrectly suggest tube misplacement [24]. Observation of the flow curve on a respiratory function monitor can detect correct placement of the endotracheal tube and has been shown to be more accurate as well as quicker in detecting the correct tube position when compared to colorimetric CO2 detector [25].
Thoracic ultrasound accuracy for the investigation of initial neonatal respiratory distress
2019, Archives de PediatrieUltrasound-guided lung sliding sign to confirm optimal depth of tracheal tube insertion in young children
2019, British Journal of AnaesthesiaTeaching Flight Nurses Ultrasonographic Evaluation of Esophageal Intubation and Pneumothorax
2019, Air Medical Journal
- ☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.11.028.