Elsevier

Resuscitation

Volume 84, Issue 6, June 2013, Pages 731-737
Resuscitation

Review article
Confirmation of correct tracheal tube placement in newborn infants

https://doi.org/10.1016/j.resuscitation.2012.11.028Get rights and content

Abstract

Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms “Infant, Newborn”, “Endotracheal intubation”, “Resuscitation”, “Clinical signs”, “Radiography”, “Respiratory Function Tests”, “Laryngoscopy”, “Ultrasonography”, and “Bronchoscopy”. Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of 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

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      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].

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    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.

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