The Journal of Emergency Medicine, Vol. -, No. -, pp.

16, 2016
Copyright 2016 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.11.034

Brief
Reports
TRACHEAL TUBE POSITION SHIFT DURING INFANT RESUSCITATION BY CHEST
COMPRESSION: A SIMULATION COMPARISON BY FIXATION METHOD AND WITH
OR WITHOUT CUFF
Takeshi Ueno, MD, Nobuyasu Komasawa, MD, PHD, Nozomi Majima, MD, PHD, Ryosuke Mihara, MD, and
Toshiaki Minami, MD, PHD
Department of Anesthesiology, Osaka Medical College, Osaka, Japan
Reprint Address: Nobuyasu Komasawa, MD, PHD, Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki,
Osaka 569-8686, Japan

, AbstractBackground: Tracheal tube placement during

infant resuscitation is essential for definite airway protection.
Accidental extubation due to tracheal tube displacement is a
rare event, but it results in severe complications, especially in
infants. Objective: The present study evaluated how infant
tracheal tube displacement is affected by tape vs. tube holder
fixation using a manikin. Methods: A tracheal tube with internal diameter of 3.5 mm was placed 10 cm from the gum
ridge in an advanced life support (ALS) Baby simulator
(Laerdal, Stavanger, Norway). In the first trial, cuff pressure
was set at 15, 20, and 25 cmH2O and trials were performed at
each setting with no fixation, Durapore (3M, St Paul, MN)
tape fixation, Multipore (3M) tape fixation, and Thomas
Tube Holder (Laerdal) fixation. After 5 min of chest
compression, the tracheal tube shift was measured. In the
second trial, we compared the tube shift by chest compression with or without cuff in the same way. Results: Relative
to no fixation, tracheal tube shift was significantly less in
the Durapore, Multipore, and tube holder groups
(p < 0.05) at all cuff settings. Of the three fixation methods,
the tube holder showed significantly less shift (p < 0.05) relative to tape, regardless of the initial cuff pressure. The positional shift after chest compressions was significantly larger
in the trials with cuff than in those without cuff in Durapore
or Multipore fixation (p < 0.05), but did not in tube holder
fixation. Conclusions: There is less tracheal tube displace-

ment with tube holder fixation than with tape during

continuous infant chest compression simulation. The tube
cuff can contribute to the positional shift of the tube during
infant chest compression. 2016 Elsevier Inc.
, Keywordstracheal tube; position shift; chest compression; infant; tube fixation; simulation

INTRODUCTION
Asphyxial cardiac arrest is more common than ventricular
fibrillation cardiac arrest in infants and children, and
definite tracheal intubation is extremely important in
infant resuscitation (1,2). Once tracheal intubation is
completed, continuous chest compression is possible
because there is definite separation and protection of the
trachea from the esophagus and stomach and the quality
of chest compressions can be measured by assessing
end-tidal CO2 values (3). Endotracheal tube placement
during resuscitation is important for definite tracheal protection, especially in infants and children. After successful
endotracheal intubation, the infant endotracheal tube must
be secured to prevent movement of the tube that can result
in extubation (4). Accidental extubation due to endotracheal tube displacement results in severe complications.
Unplanned infant extubation has been reported
frequently in the context of critical care, but very little

This work was supported by institutional and departmental

funding.

RECEIVED: 7 August 2015; FINAL SUBMISSION RECEIVED: 3 November 2015;

ACCEPTED: 20 November 2015
1

T. Ueno et al.

research has examined its frequency of this in the emergency department or in the context of resuscitation
(46). Activities that involve patient movement are
known to increase the risk of unintentional extubation,
and it seems likely that patients who are intubated
during chest compression will exhibit a high risk of
accidental extubation.
Tracheal tube displacement leading to accidental
extubation during infant resuscitation is a rare event, but
can lead to severe complications. Therefore, the present
study evaluated tracheal tube displacement, as it is affected
by various fixation methods in a manikin and autochest
compression machine simulation. Specifically, we
compared adhesive extensive tape, nonextensive tape,
and tube holder fixation, with no fixation set as a control.
We hypothesized that the infant tracheal tube would
shift with continuous chest compression, and that the fixation method would affect this shift. As a clinical evaluation of such fixation during resuscitation would be
unethical, we decided to use the infant manikin to
compare fixation methods.
MATERIALS AND METHODS
The advanced life support (ALS) Baby manikin (Laerdal, Stavanger, Norway), which is designed to represent
a 3-month-old infant (11 lb), was used for tracheal tube
placement and continuous chest compression (7,8). The
cuffed internal diameter of the tracheal tube
(Mallinkrodt; Covidien, MA, USA) was 3.5 mm. We
placed the tracheal tube at 10 cm from the gum ridge in
the baby manikin. The manikin or tracheal tube was
well prepared with attached lubricant before the study.
For the first experiment, cuff pressure was adjusted to
15, 20, and 25 cmH2O. Cuff pressure adjustments were
performed with an automated cuff pressure controller
(Mallinckrodt Pressure Control; Covidien, Dublin,
Ireland), which perform automated calibration and
contains accuracy down to 1 decimal place, according to
the manufacturer. After tracheal tube placement and cuff
pressure adjustment, the following four fixation methods
were compared: 1) no fixation; 2) adhesive nonextensive
tape (Durapore; 3M, St Paul, MN); 3) adhesive
extensive tape (Multipore; 3M); and 4) pediatric tube
holder (Thomas Tube Holder; Laerdal, Stavanger,
Norway) (Figure 1AD).
Next, 5 min of continuous chest compression was performed by two-thumb method according to the 2010
European Resuscitation Council Guidelines (2). After
5 min of chest compressions, the incidence of accidental
extubation and the extent of tube shift from gum ridge to
the point of displacement were measured with the same
ruler, which contains scale down to 1 decimal millimeter.
Trials were performed five times in each setting.

For the second experiment, tracheal tubes with or

without cuff were used among the three fixation methods.
The cuff pressure in the tube with cuff was set at 20
cmH2O. Tracheal tube position shift was measured as
the first experiment. All of the experimental procedures
were conducted by authors.
Statistical Analysis
Differences in infant tracheal tube shift were analyzed by
two-way repeated measures analysis of variance followed
by Tukeys multiple comparisons. Results are expressed
as mean 6 standard deviation. A p value < 0.05 was
considered statistically significant.
RESULTS
Tracheal Tube Shift After 5-Min Chest Compression
Relative to that with no fixation, infant tracheal tube shift
was significantly less with Durapore tape fixation, Multipore tape fixation, and tube holder fixation (p < 0.05) at
all cuff pressure settings (15 cmH2O: no fixation
0.56 6 0.23 mm, Durapore 0.22 6 0.04 mm; Multipore
0.18 6 0.08 mm, and tube holder 0.04 6 0.05 mm; 20
cmH2O: no fixation 0.66 6 0.19 mm, Durapore
0.20 6 0.07 mm, Multipore 0.20 6 0.10 mm, and
tube holder 0.02 6 0.04 mm; 25 cmH2O: no fixation
0.56 6 0.21 mm, Durapore 0.22 6 0.04 mm, Multipore
0.18 6 0.07 mm, and tube holder 0.04 6 0.04 mm).
Among the three fixation methods, the tube holder
showed significantly less shift relative to both tapes,
regardless of the initial cuff pressures (p < 0.05)
(Figure 2). There were no significant differences among
the cuff pressures in each fixation methods.
Tracheal Tube Shift in Tracheal Tube With Cuff and
Without Cuff
Figure 3 shows the positional shift of the infant tracheal
tube with or without cuff. The amount of tracheal tube
shift was significantly higher with cuff than without
cuff when the tube was fixed with Durapore or Multipore (Durapore; with cuff: 0.20 6 0.06 mm, without
cuff: 0.02 6 0.04 mm. Multipore; with cuff:
0.20 6 0.09 mm, without cuff: 0.02 6 0.04 mm;
p < 0.05 each). In contrast, the amount of positional
shift did not differ significantly between with or without
cuff in the tube holder fixation trials (with cuff
0.02 6 0.04 mm, without cuff 0.02 6 0.04 mm). In
the comparison of fixation methods, the degree of positional shift did not differ among the fixation methods,
although, as mentioned, it was significantly larger in
the cuffed tube with tape fixation compared with the
cuffed tube with tube holder fixation (p < 0.05).

Tracheal Tube Shifts with Infant Chest Compression

Figure 1. Fixation methods. (A) No fixation of the tracheal tube. (B) Tube fixation by Durapore adhesive nonextensive tape. (C)
Tube fixation by Multipore adhesive extensive tape. (D) Thomas Tube Holder.

DISCUSSION
Airway management is considered an essential element
for both in-hospital and out-of-hospital infant cardiopulmonary resuscitation (CPR) (9,10). Current European
Resuscitation Council Guidelines for pediatric
resuscitation emphasize the importance of airway
management with as few interruptions as possible (2).
After confirmation of infant tracheal tube placement,
tracheal tube fixation is highly critical because even a
small tracheal tube shift can result in accidental extubation or one-lung ventilation. In adult studies, securing
the tracheal tube during the use of a tube holder, or
wire anchoring the tube to the oral cavity, can reduce

the incidence of unplanned extubation (11,12).

However, there are few studies regarding the best tube
fixation method for infant resuscitation.
In our study, the infant tracheal tube was found to shift
from the trachea to the oral cavity during chest compressions. Even with Durapore or Multipore tape fixation,
non-negligible tracheal tube shift was observed. These
results are compatible with those of adult simulations,
and it might be because of the repetitive intratracheal pressure caused by chest compressions, which causes a continuous air stream to flow from the trachea to the mouth, as
has been demonstrated by end-tidal CO2 volumes
measured by capnography (2,4). Chest compression can
also cause a slight increase in the intratracheal pressure,

T. Ueno et al.
0.9

Tracheal tube movement (cm)

0.8
0.7
0.6
0.5

15cmH2O
20cmH2O

0.4

25cmH2O

0.3

0.2

0.1

Other studies on adult cadavers and manikins have

also indicated that the tube holder provides more effective
resistance to extubation than adhesive tape (15,16). The
present study demonstrated that although adhesive tape
provided more resistance to extubation than no fixation,
tube movement was still detected. Consistent with
previous studies conducted in intensive care settings,
we would recommend using a tube holder to stabilize
the infant tracheal tube during chest compression (5,6).
LIMITATIONS

0
No fixation

Durapore

Multipore

Tube Holder

Figure 2. Tracheal tube movement by infant chest compression (mean standard deviation) at initial cuff pressure at 15,
20, and 25 cmH2O. Durapore, Durapore adhesive nonextensive tape; Multipore, Multipore adhesive extensive tape;
Tube holder, Thomas Tube Holder. Differences were
analyzed by two-way analysis of variance. NS, no significant
difference; *p < 0.05 compared with the other three simulations; #p < 0.05 compared with no fixation.

leading to bronchospasm or laryngospasm (13,14). Just as

chest compression is recommended to alleviate choking in
infants and adults, the same mechanism of intratracheal
pressure increase can occur through infant chest
compression during infant cardiorespiratory arrest (2).
The finding that the positional shift is greater in the cuffed
tube (cuff inflated to 20 cmH2O) than in the cuffless tube
with tape fixation (Durapore or Multipore) indicates that
the intratracheal pressure increase is transmitted to the
cuffed tube, but released in the cuffless tube.
In contrast, the tracheal tube shift was significantly
diminished with tube holder compared with the other
three fixations that were also compatible with the result
of adult simulation (4). A tube holder is expected to be
a more reliable method for securing the infant tracheal
tube, which could otherwise be dislodged by the repetitive extubation force of the chest compressions.

Our study has several limitations. First, the plastic

manikin would perform differently than human airway
tissue in various points. Specifically, air pressure for the
cuffed tube might have caused more significant movement in the plastic airway than in the human airway,
where greater elasticity is present. Second, because we
used an infant manikin, certain factors encountered in
clinical use, such as blood, vomit, and sputum in the
oropharynx, were not mimicked in our simulations (17).
Third, in clinical situations, the homogeneity of CPR
techniques cannot be assured. Fourth, we evaluated
tracheal tubes with only one cuff type. The amount of
tracheal tube positional shift can also differ, depending
on the cuff type (18).
Future studies to obtain clinical data on infant tube
displacement, as well as ethically sound randomized clinical trials comparing tracheal tube fixation methods during chest compression are required.
CONCLUSIONS
A lesser degree of infant tracheal tube displacement
occurred with tube holder fixation than with tape fixation
during simulation of continuous infant chest compression. The tracheal tube cuff can contribute to the positional shift of the infant tracheal tube during chest
compression.
AcknowledgmentsTakeshi Ueno and Nobuyasu Komasawa
contributed to the study design, study implementation, data
analysis, and manuscript preparation. Nozomi Majima contributed to the study design, data collection, data analysis, and
manuscript preparation. Ryosuke Mihara contributed to the
data collection, and Toshiaki Minami contributed to the study
design and manuscript preparation. All authors discussed the
results and approved the final manuscript.

Figure 3. Comparison of tracheal tube shift during infant

chest compression with or without cuff (mean standard deviation). Durapore, Durapore adhesive nonextensive tape;
Multipore, Multipore adhesive extensive tape; Tube holder,
Thomas Tube Holder. Differences were analyzed by twoway analysis of variance. NS, no significant difference;
*p < 0.05 compared with tube without cuff.

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Tracheal Tube Shifts with Infant Chest Compression

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T. Ueno et al.

ARTICLE SUMMARY
1. Why is this topic important?
Tracheal tube placement during infant resuscitation is
essential for definite airway protection. Accidental extubation due to tracheal tube displacement is a rare event,
but it results in severe complications, especially in infants.
2. What does this study attempt to show?
The present study evaluated infant tracheal tube shift
with continuous chest compression and how tracheal
tube displacement is affected by tape vs. tube holder fixation using a manikin. We also hypothesized the cuff affects the infant tracheal tube shift and evaluated the
displacement with or without cuff.
3. What are the key findings?
Relative to no fixation, tracheal tube shift was significantly less in the Durapore, Multipore, and tube holder
groups (p < 0.05) at all initial cuff settings. Of the three
fixation methods, the tube holder showed significantly
less shift (p < 0.05) relative to tape regardless of the initial
cuff pressure. The positional shift after chest compressions was significantly larger in the trials with cuff than
in those without cuff.
4. How is patient care impacted?
Tube holder fixation is effective for tracheal tube fixation during infant chest compression. The tube cuff can
contribute to the positional shift of the tube during infant
chest compression.