Proper Depth of Placement of Oral Endotracheal Tubes in Adults Prior to Radiographic Confirmation

Abstract

Objective: To determine whether a certain distance measurement on the oral endotracheal tube (ETT) at the corner of the mouth could reasonably ensure proper depth of placement in critically ill patients, without the immediate need for a confirming chest x-ray (CXR).Methods: A prospective observational cross-sectional design was used to compare ETT mark distance and radiographic location of the ETT tip. The measurement marking on the ETT at the level of the corner of the mouth was noted at the time of intubation. The relationship of the tip of the ETT to the tracheal carina on the postintubation CXR was then determined. The ETT placement was deemed correct if the tip was at least 2 cm cephalad to the carina on the CXR. Results:Of 83 intubated patients assessed, 52 were men and 31 women. The mean measurement on the ETT at the corner of the mouth was 22.2 cm for the women and 23.1 cm for the men. The mean distance from the tip of the ETT to the carina was 3.45 cm for the women and 4.13 cm for the men. Seventy-five of the 83 patients (90.4%; 95% CI 81.9-95.7%) had correct ETT positions on the initial CXR. If the ETT position had been adjusted at the corner of the mouth to 21 cm for the women and 23 cm for the men, the ETT would have been in correct position for 81 of the 83 patients (97.6%; 95% CI 89.6-99.7%). This represents a significant improvement in tube placement (p < 0.025; the McNemar chi-square). Conclusion:Proper depth of ETT placement in the critically ill adult patient can be estimated by the technique of this study. In this adult patient population, corner-of-the-mouth placement of the ETT using the 21-cm tube mark for the women and the 23-cm mark for the men would have led to proper placement for most patients.Acad. Emerg. Med. 1995; 2:20-24.

How Much Force Is Required to Dislodge an Alternate Airway?

“…We placed a size 8-0 ETT using direct laryngoscopy to a depth of 23 cm at the lip for male cadavers and 21 cm at the lip for the female cadaver. 9 We confirmed placement by direct visualization of the ETT between the vocal cords. 10 We inflated the ETT cuff to 20-25 cmH 2 0.…”

Proper Depth of Placement of Nasotracheal Tubes in Adults Prior to Radiographic Confirmation

“…For purposes of uniformity with recent studies of Roberts et al 9 and general clinical practice,'-' we chose to conform with the criteria of "adequate" tube placement defined as " 2 2 cm above the carina." However, Goodman et al proposed an alternative ideal height above the carina of 5 2 2 cm with the head in the neutral p0siti0n.l~ This was based on the findings of Conrardy et al that neck flexion advances the ETT by as much as 3.1 cm (mean 1.9 cm), and extension withdraws the ETT by as much as 5.2 cm (mean 1.9 cm), raising concerns over the safety of placing the ETT tip at precisely 2 cm above the carina, or high in the trachea."…”

Are anatomical landmark measurements accurate for predicting endotracheal tube depth?

“…Conversely, Roberts et. al used >2 cm from the carina for the proper placement of the ETT and concluded that placing the ETT according to the 21/23 method resulted in 97.6% correct placement [14]. More recent studies have found less beneficial results with this method suggesting this method should not be considered a more reliable method than the topographical measurements.…”

“…Had these depths been utilized, migration away from the carina would have likely induced vocal cord impingement, especially due to the longer cuff length of polyurethane HVLP ETTs [10]. In adults, multiple methods have been described for selecting the insertion level of an endotracheal tube (ETT) [3][4][5][14][15][16][17][18][19][20][21]. Owen et.…”