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The Impact of Postintubation Chest Radiograph During Pediatric and Neonatal Critical Care Transport

Sanchez-Pinto, Nelson MD1; Giuliano, John S. MD2; Schwartz, Hamilton P. MD3; Garrett, Lynne RN4; Gothard, M. David MS5; Kantak, Anand MD6; Bigham, Michael T. MD7

Pediatric Critical Care Medicine: June 2013 - Volume 14 - Issue 5 - p e213–e217
doi: 10.1097/PCC.0b013e3182772e13
Online Clinical Investigations

Objectives: Tracheal intubation is necessary in the setting of pediatric/neonatal critical care transport but information regarding usefulness and efficiency of a confirmatory postintubation chest radiograph is limited. We hypothesize that routine postintubation chest radiograph to confirm tracheal tube position is not informative and can be eliminated to improve efficiency without compromising safety in transport.

Design: This was a prospective observational study. The primary study outcome was the rate of tracheal tube repositioning after postintubation chest radiograph and the secondary outcome was the on-scene time. Additional data obtained included the initial accuracy of tracheal tube depth based on Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines.

Setting: A children’s hospital-based pediatric/neonatal critical care transport team in northeastern Ohio.

Patients: All pediatric/neonatal patients intubated by the transport team during the 18-month study period (January 2009—July 2010).

Measurements and Main Results: There were 77 patients enrolled (43 pediatric, 34 neonatal). A postintubation chest radiograph was obtained 85.7% of the time and showed tracheal tube malposition in 47% of cases. No difference was seen in the rate of malpositioned tracheal tubes in the neonatal group compared with pediatric group (51.7% vs. 43.2%, p = 0.54). The calculated tracheal tube depth based on the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines was correct in 50% of the neonates and 41.9% of the pediatric patients. In patients with appropriate initial tracheal tube depth by calculations, the tracheal tube was repositioned at similar rates after postintubation chest radiograph in both neonatal and pediatric patients (50% vs. 41.9%, p = 0.48). When comparing mean onscene times for patients with/without a postintubation chest radiograph, the neonatal patients saved 33 minutes on average when no chest radiograph was obtained (mean ± sd: 60.6 ± 35.8 min vs. 93.8 ± 23.8 min, p = 0.01). There was no statistical difference in on-scene time for pediatric patients whether they did or did not receive a postintubation chest radiograph.

Conclusions: Although postintubation chest radiographs may extend the overall on-scene transport times in select patients, our data show that the postintubation chest radiographs remain informative in pediatric/neonatal critical care specialty transport and should be obtained when feasible.

1Department of Pediatrics, Division of Critical Care Medicine, Los Angeles Children’s Hospital, Los Angeles, CA.

2Department of Pediatrics, Division of Critical Care Medicine, Yale Children’s Hospital, CT.

3Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, OH.

4Department of Nursing, Transport Services, Akron Children’s Hospital, OH.

5Rebecca D. Considine Research Institute, Akron Children’s Hospital, OH.

6Department of Pediatrics, Division of Neonatology, Akron Children’s Hospital, OH.

7Department of Pediatrics, Division of Critical Care Medicine, Akron Children’s Hospital, OH.

Supported, in part, by a grant from Transport Department and the Rebecca D. Considine Research Institute.

The authors have not disclosed any potential conflicts of interest.

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©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies