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Pediatric Critical Care Medicine:
doi: 10.1097/01.PCC.0000165802.32383.9E
Feature Articles

Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children*

Phipps, Lorri M. RN, MSN, CPNP; Thomas, Neal J. MD, MSc; Gilmore, Raymond K. RN, BSN; Raymond, Jill A. RN, BSN; Bittner, Toni R. RN, BSN; Orr, Richard A. MD; Robertson, Courtney L. MD

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Objective: To determine whether multiplying the internal diameter of the endotracheal tube (ETT) by 3 (3× ETT size) is a reliable method for determining correct depth of oral ETT placement in the pediatric population.

Design: Prospective, observational.

Setting: University-affiliated, 12-bed pediatric intensive care unit.

Patients: Orally intubated pediatric intensive care unit patients of ≤12 yrs of age.

Interventions: Demographics, ETT size, and depth of ETT placement measured from the lip were obtained. Correct placement, defined as the tip of the ETT below the thoracic inlet and ≥0.5 cm above the carina, was determined by chest radiograph.

Measurements and Main Results: Suggested ETT size based on the Pediatric Advanced Life Support (PALS) age-based formula and the Broselow tape-length–based guidelines were determined. A total of 174 of 226 ETTs (77%) were correctly positioned. If practitioners utilized the 3× ETT size for the actual tubes chosen, 170 of 226 (75%) would have been accurately placed. More accurate were the 3× PALS–based ETT size (81%) and 3× Broselow–suggested ETT size (85%). The use of the Broselow ETTs to determine the depth would have led to a significantly improved ETT position (p = .009) compared with the actual ETT.

Conclusion: The commonly used formula of 3× tube size for ETT depth in children results in 15–25% malpositioned tubes. Practitioners can improve the reliability of this formula by utilizing the recommended ETT size as suggested by the Broselow tape. A more reliable method is necessary to avoid ETT malposition.

©2005The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies


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