1344581 - ENDOTRACHEAL TUBE PALPATION TO ASSESS ENDOTRACHEAL DEPTH

William P. McKay ,
1
Jim Klonorakis
1
, Vladko Pelivanov
1

1. Anesthesia, University of Saskatchewan, Saskatoon, SK, Canada

Introduction: Correct endotracheal tube (ETT) depth placement is achieved when the distal tip is in mid-
trachea with the head in neutral alignment. This study reports a study of palpation of the trachea during
intubation to achieve correct ETT depth. A similar technique is useful in newborns.[1] When palpating the
anterior neck over the trachea during intubation, one can feel the tip of the ETT move down the trachea as the
tracheal rings move slightly forward one by one as it slides by, enabling determination of tip position.

Methods: With Research Ethics Committee approval, ASA I and II patients expected to be intubated for elective
surgery were recruited. Unstable patients and those with reflux or difficult airways were excluded. Induction and
intubation were accomplished by the clinical anesthesiologist, who was asked simply to advance the tube
slowly once it is through the cords. The trachea was palpated with 3 fingers by an investigator: the index
fingertip over the cricothroid membrane, the ring finger in the sternal notch, and the middle finger over the
anterior trachea between. As the ETT is advanced, its tip can be felt moving down the trachea as it passes each
finger. When the ETT tip was felt in the sternal notch, the anesthesiologist was asked to stop advancing the ETT
and immobilize it. Its position in the trachea was then determined by fibre-optic bronchoscopy.

Results: 79 patients were approached, and 77 consented to the study. The movement of the ETT in the sternal
notch was easily or moderately easily palpated in 60 patients (palpable); barely palpable or impalpable in 17
(see Table). Ease of palpation was inversely correlated with age (R =-0.27). Smokers, diabetics, and obese
patients all had higher percentages of difficult palpation (table). In subjects where the ETT motion was palpable,
The ETT tip was too shallow (<2cm from cords) in 2 and too deep (<2cm from carina) in 7. Of the 7 with ETT too
deep, 4 had depth-at-teeth <21cm for females, and <23cm for males, widely used measurements to set the
correct ETT depth.[2]

Discussion: Elderly, diabetic, and smoking patients have rigid tracheal rings that do not allow determination of
ETT position by this technique. More ETTs were too deep than too shallow. It appears that the trachea is pulled
upward relative to the boney thorax in achieving sniffing position. Further research will study and determine an
optimal adjustment for this. Some of the misplacements were attributable to the first introduction of the
technique to the involved clinical anesthesiologist, with better precision on subsequent patients. However, it
appears to be quickly learned; more research will be needed to determine this and its ultimate clinical value.
Measurement of ETT depth at teeth does not reliably predict safe ETT depth. This simple technique shows
promise, with refinement, of clinical utility in placing the ETT at the correct depth and avoiding unnecessary
xrays in intensive care units.

References: [1] J ain A et al. Resuscitation 2004; 60(3): 297
[2] Owen RL, Cheney FW. Anesthesiology 1987; 67: 255

Ease of palpation
Easy or
moderate
Barely or
impalpable
Number of subjects 60 17
Smokers (%) 21 (35) 12 (71)
Diabetes 5 (8.3) 2 (11.7)
BMI >30 20 (33) 9 (53)