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ASSESSMENT OF THE DEPTH OF

61 ENDOTRACHEAL TUBE IN PEDIATRIC
USING FLUOROSCOPY TECHNIQUE:
A1, PILOT
STUDY.
2
Hasmizy M
W Lynn Xuan
, Siti Baiduri B1, Hanafi S1, Norzalina E1.
Department of Cardiothoracic Anaesthesiology and Perfusion, Sarawak Heart Centre, Kota Samarahan,
Sarawak.
2
Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Kuching, Sarawak
1

Introduction
In children, precise depth of endotracheal tube
(ETT) insertion is important to avoid inadvertent
tracheal extubation or endobronchial intubation.
We practiced anchor ETT at the patient lips based
on: a) formula: age/2 +12 for children > 1 year
old and ETT internal diameter (ID) x 3 for children
< 1 year old and b) chest auscultation for bilateral
breath sound.

Results
Table 1. Patient Characteristics

Objective
To determine the accuracy of standard practice for
estimating placement of ETT depth in children by
using fluoroscopy.
Table 2: Statistics of Measured (D) and Calculated
(DA) ETT

Methods
We included 42 paediatric patients undergoing
interventional cardiac catheterization under
general anaesthesia using orotracheal intubation.
After inhalation or intravenous
induction of
anaesthesia and complete neuromuscular block,
the patients’ tracheas were intubated.
ETT sizes were selected according Pediatric
Advanced Life Support guideline. An uncuffed ETT
size for infants (3.5-mm ID), between 1 - 2 years
of age (4.0-mm ID), age > 2 year (age in yr/4 + 4,
mm ID).
Estimated ETT depth based on formula: ID x 3 for
< 1 year old or age/2 + 12 for >1 year old (E1).
However, the final ETT depth placement at the lips
will depends on equal auscultation of bilateral
breath sounds (E2).
Fluoroscopic images were taken with the head in
neutral positions. Calibration of the measurement
system
was
performed
by
electronically
measuring the diameter of a standard ruler. Then,
the distance of the distal tip of ETT to the carina
was measured (D).
The supposed distance of the distal tip ETT to the
carina based on Pediatric Advanced Life Support
guideline (DA) was calculated with formula: DA =
D – (E1-E2).
Figure A:
Endotracheal tube
position and standard
ruler are shown by
fluoroscopy.

Figure B: Calibrated
fluoroscopy measured
the distance between the
carina and the distal tip
of the ETT (D).

Discussion
There are a variety of techniques for predicting
the correct depth of ETT such as the use of depth
markers present on the distal end of tracheal
tubes, the use of formulae and standard reference
charts. Lee et. al found that flexible fiberoptic
bronchoscopy was convenient and time saving
technique in ETT positioning compared with chest
radiography.
Our study showed that the chest auscultation for
estimating ETT depth in infants and children
resulted in no endotracheal intubation and only 3
patients had the distal tip of ETT < 0.5 cm from
the carina compared to 5 patients will have
endotracheal intubation and 8 patients will have
the distal tip of ETT < 0.5 cm from the carina in
calculated ETT group. Our data suggested that
the commonly used PALS formula for predicting
ETT length will lead to high incidence of
endotracheal intubation. Our results were different
from Verghese, who found that despite bilateral
breath sounds being heard, endobronchial
intubation was demonstrated by fluoroscopy in
12% of the patients.
Although Chest X-ray remains the “gold standard”
for confirming appropriate tube placement, it can
be replaced by fluoroscopy if patient already using
it for interventional procedure.

Conclusion
ETT depth age-formula alone as suggested by
PALS guideline without clinical assessment will
results in high incidence of endobronchial
intubation and low placement of the ETT.

References

•Mariano et. al. A comparison of three methods for
estimating appropriate tracheal tube depth in children.
Pediatric Anesthesia. 2005;15: 846–851.