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assessment of the correct positioning of oral endotracheal tubes in critical care patients
- Jennifer A Cuthill, Claire McGroarty, Andrew Inglis, Catriona Macneil (28 May 2008)
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Jennifer A Cuthill, specialist registrar southern general hospital, glasgow, Claire McGroarty, Andrew Inglis, Catriona Macneil
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We read with interest the recent article regarding the length of standard tracheostomy tubes in critical care patients [1]. The authors found that most standard tubes are too short for the average critical care patient and that this can lead to increased morbidity. A recent audit carried out in our intensive care unit, highlights that this is not just a problem which occurs exclusively with tracheostomy tubes. Indeed, the correct positioning of oral endo-tracheal tubes in the critically ill patient is also problematic. A previous study involving 219 critically ill patients showed that 14% of these patients required re-positioning of their endo-tracheal tube following chest x-ray with 5% having main-stem intubations. 60% of these main-stem bronchus intubations had equal and bilateral breath sounds on chest auscultation suggesting that clinical examination alone is not sufficient in assessing correct positioning [2]. We assessed the initial endo-tracheal tube position in every admission to our intensive care unit over a two month period (January – February 2008). Review of each post-intubation chest x-ray was carried out as part of the study. Acceptable positioning of an endo-tracheal tube was taken to be between 2 to 6 centimetres above the carina. Correct endo- tracheal tube position decreases the risk of endo-bronchial intubation during movement of the patient, either spontaneously or during nursing care [3]. In addition, we also assessed whether the position of the endo- tracheal tube was documented in the case notes. There were 43 admissions in the two month period, 40 of whom had an endo-tracheal tube present. Only 28 (70%) of these patients had a chest x -ray carried out within the 24 hours following intubation. 22 of these patients (78%) had a correctly positioned endo-tracheal tube with 3 (11%) being classed as ‘too high’ and 3 (11%) as ‘too low’. The position of the endo-tracheal tube was documented in the case notes in only 8 patients (20%) and no patient had their endo-tracheal tube re-positioned. We have since made several changes to current practice in our unit. We recommend that 100% of new admissions to intensive care should have a post-intubation chest x-ray carried out with the results and position of the endotracheal tube at the teeth documented in the case notes. This also includes inter-hospital transfers if a ‘hard copy’ chest x-ray is not available or if the position of the endo-tracheal tube at the teeth prior to transfer is not documented. We suggest that any re-positioning of the endo-tracheal tube following initial chest x-ray should also be documented in the case notes to allow reference to the initial chest x-ray. These changes have been easy to implement by way of presentations, posters situated beside the x-ray viewing computer and regular verbal reminders. Our new recommendations will also be incorporated into the new version of the intensive care unit trainees’ handbook. We are currently re-auditing practice and hope that these simple measures will significantly reduce the morbidity and possible mortality of our patients. References 1. Mallick A, Bodenham A, Elliot S, Oram J. An investigation into the length of standard tracheostomy tubes in critical care patients. Anaesthesia 2008; 63: 302-6. 2. Brunel W, Coleman DL, Schwartz DE. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989; 96: 1043-5. 3. Tim B Hunter MD et al. Medical Devices of the Chest. Radiographics 2004: 24 1725-1746 Conflict of Interest:None declared |
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