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Digital Palpation of Endotracheal Tube Tip as a Method of Confirming Endotracheal Tube Position in Neonates: an Open-label, Three-armed Randomized Controlled Trial

Presented at the Neonatal Society 2013 Spring Meeting.

Saboo A1, Dutta S1, Sodhi KS2

1 Neonatal Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Background: Due to the short airways in premature neonates, an accurate position of the endotracheal tube (ETT) after orotracheal intubation, is crucial for adequate mechanical ventilation. After intubation, the incidence of malposition of the tip of the ETT on radiography can be as high as 50% (1). A chest Xray (CXR) to evaluate placement is often not immediately available in the delivery room and clinical examination is unreliable in ascertaining depth of intubation (2). Unlike nomogram based methods, digital palpation offers a direct method to determine the ETT tip position. There is only one randomized control trial (RCT) showing applicability of suprasternal digital palpation technique for ETT tube positioning in neonates (3).

Methods: Design: Open-label, RCT. Setting: Level III NICU. Subjects: All new born babies admitted in NICU requiring intubation. Interventions: Subjects were randomly allocated to one of three groups, wherein IL was determined by; 1. weight-based nomogram alone, or; 2. weight-based nomogram combined with suprasternal palpation of ETT tip performed by specially trained Neonatology fellows, or 3;. combination of weight-based and suprasternal methods by personnel not specially trained. Primary Outcome: Rate of malposition of ETT as judged on CXR. The Institute Ethics Committee approved the protocol. We sought permission to obtain deferred consent in cases where there was no time to seek consent, but when time was available for randomization. In other cases, we obtained informed written consent from a parent prior to patient enrolment.

Results: 57 babies were randomized into group 1 (n=15), group 2 (n=20) & group 3 (n=22). The proportion of correct ETT placement was highest in group 2; being 66.7%, 83.3% and 66.7% in groups 1 through 3 respectively (p value = 0.58). No complication was attributable to the palpation technique. 

Conclusion: Suprasternal palpation shows promise as a simple, safe, teachable method of confirming ETT position in neonates.

Corresponding author: ashwinrsaboo@gmail.com

References
1. Kuhns LR, Poznanski AK. Endotracheal tube position in the infant. J Pediatr. 1971 Jun;78(6):991-6
2. Verghese ST, Hannallah RS, Slack MC, Cross RR, Patel KM. Auscultation of bilateral breath sounds does not rule out endobronchial intubation in children. Anesth Analg. 2004 Jul;99(1):56-8
3. Jain A, Finer NN, Hilton S, Rich W. A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates. Resuscitation. 2004 Mar;60(3):297-302

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