Presented at the Neonatal Society 2006 Spring Meeting.
Moreiras JW, Petrone FL, Kempley ST
London Neonatal Transport Service, Barts and the London NHS Trust, London, UK
Background: A previous audit of Endotracheal Tube (ETT) placement in neonates referred for transfer by our service demonstrated that many had been placed too low. Final adjusted ETT length correlated well with gestation. These findings were presented at BAPM and at local clinical governance meetings prior to this study.
Aim: To determine whether ETT placement had changed since the original audit and to evaluate the effects of an education drive to optimise ETT placement.
Method: In this study, baseline data were collected prospectively over a 3-month period (100 ventilated transfers). The study was approved by the clinical governance committee of the service. During the next month the education drive was implemented, followed by a further 3-month period of data collection (108 ventilated transfers). Of 33 hospitals in London invited to participate in the education drive, 24 agreed. They were issued with gestation-based guidelines for ETT length, generated from the original audit (Table 1a), to be displayed on resuscitation trolleys. The education drive involved transport team fellows alerting staff to the audit, distribution of credit card size laminated versions of the table to staff on participating units and a presentation to a regional registrar training day. Audit data included patient demographics, details of ETT placement and assessment of chest radiographs. ETT’s were repositioned if the tip of the tube was below T2, above T1, or if its position was thought to be causing problems with ventilation.
Results: After the education drive 36% of ETT’s required repositioning, compared with 43% in the pre-education period (p=0.3) and 58% in the original audit (p<0.01). The education drive had no significant overall effect on mean thoracic ETT position (pre T2.4, post T2.4), nor was there any effect on the overall radiological findings or complications of intubation. The number of transfers in which gestation was used to guide ETT length increased from 18% to 32% (p=0.02). In the 53 patients where gestation was used to guide ETT length, 2% had uneven lung expansion (compared to 18% with other methods, p=0.03) and only 15% needed ETT repositioning (compared to 48%, p<0.01). Two way ANOVA showed that gestation guidance had a greater effect on ETT position in participating centres (F=5.3, p=0.02) (Table 2). Regression of final ETT length against gestation (linear) and weight (logarithmic) based on our study’s data has been used to generate revised recommendations for ETT length (Table 1b).
Conclusion: When gestation was used to guide ETT placement it was found to be a reliable method for estimating initial ETT length at the lips, resulting in more even lung expansion. The education drive had some effect on practice, but with limited uptake of the recommendations, the improvement in ETT position in the whole cohort was not significant. We would recommend further dissemination of these or similar evidence-based tables for guiding initial ETT position.