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Confirmation of Endotracheal Tube Positioning
~ ~IIIIIII---c_o_m_m_un_ic_at_io_n_s_to_th_e_e_d_ito_r COl1l1nunication.~ Jor this section
t!'ill be published liS space lind prioritit's penn it. TIl(' C011l1nents should not l~xceed .3.50 word~ in l('ngth. with a TJulxi,nu,n of fi()(· njen'nces; one fifI,un' or table can hi' printl·d. f:xc{'l'tions 11Uly occur undi'r particular circu,nstances. Contributions 11Wy includlJ. co,nl1U'nts on articles published in this periodical, or thl'y TTUlY bl' reports oj unique educational character. ST)('cific 1)(~lission to ,mblish shoultl be cited in a cov(~ring left('r or 11l'l'endl·d as a postscript.
of an ET moved from 0.7 to 1.9 cm dependin~ upon head position, and as much as 5.2 cm with extension from a neutral position. Our data aJ.tree with these observations. Bnlnel et al noted that centimeter markings of ET is not reliable, but we eannot a~ree. Finally, we should like to inquire about the accuracy of the numbers "10 percent" and "78 percent (seven of nine)" in the discussion. Yukio Kubota, M.D.; Yoshiro Toyoda, M.D.; Hiroshi Kubota, M.D., and Yoshio Yanwsaki, M.D., Osaka Kohseinenkin Hospital, Osaka, japan
Confirmation of Endotracheal Tube Positioning UJ the Editor:
\Ve read with interest the re<..'ent article on, "Con6rmation of Endotracheal Tube Positioning," by Bnlnel et al (Chest 1989; 96:1043-45). Confirmation of proper endotracheal tube (ET) positionin~ is important for prevention of complications such as inadvertent endobronchial intubation (EBI) and accidental extubation; also for successful selective bronchial suctioning. 1-3 We have studied placement of the ET in more than several thousand patients by means of deliberate unilateral EBI, chest auscultation, cuff ballottement in the suprasternal notch and chest roentgenographic study. Usin~ these maneuvers, we have not encountered the abovementioned complications or esopha~eal intubation. Therefore, we would like to (,'omment by citin~ our experience. \Ve found that the distan(,'e from the upper incisor teeth to the carina in women was shorter than in men.· Thus, EBI may be more common in women. In addition, a congenital short trachea, althou~h a rare occurence, should be (,'()nsidered in this connection. 5 BruneI et aI noted that 60 per(,-ent (six of ten) of main-stem bronchial intubations occurred despite the presence of equal breath sounds on auscultation. We had the same experience in our earlier studies some ten years ago. \Ve found that breath sounds could be heard over the (,'()ntralateral lung field unless the ET fit snugly, the main-stem bronchus or the bronchus completely sealed by the cuff. These observations were substantiated both by auscultation and chest roentgenograms, and are also easily proven in a lung or tracheo-bronchial model. Bnlnel et al and others6-1i did not consider the matter of cuff inRation or leakage of gas around it. Bnlnel et al noted that breath sounds may be more readily transmitted to the opposite side and cited Owen's article;" Owen in turn referenced Pollard's article. 9Neither ofthese authors addressed the matter of gas leakage. Incidentally, Pollard's article described esophageal intubation, not EBI.9 We found that breath sounds could he heard to a lesser extent over the lung field of the non-intubated side between the midclavicular line and sternal edge at the level of first and second rihs, and inaudible at the level of the fourth and fifth ribs. Also, breath sounds were totally absent at the midaxillary line of the opposite side if gas leakage was not present. The eventual site of placement of an ET is affected by the following: head position (hyperextended, neutral or flexed) when measurements are performed; fixation of the ET at the level of the lower or upper lip, or at the (,-enter or angle of the mouth; dental eonditions, edentulous or not. lb quote BruneI: "The head is usually placed in a sniffin~ position during oral ET insertion," but they did not describe head position when measurements were made and chest roent~eno~rams taken. Conrardy et al lO reported that the tip
1306
_
Reprint requests: Dr. Kubota, Chie.f Department of Anesthesia,
Osaka Kohseinenkin Hospital 4-2-78 Fuku.vhima-ku, Osaka, japan 553 REFERENCES
2
3 4
5
Kubota Y, Magarjbuchi T, Toyoda Y, Murakawa M, Urabe N, Asada A, et al. Selective bronchial suctionin~ in the adult using a curved-tipped catheter with a ~lide mark. Crit Care Med 1982; 10:767-69 Kubota Y, Toyoda Y, Kubota H, Sawada S, Asada A, Sasai S, et al. Is a strai~t catheter ne<..-essary for selective bronchial suetioning in the adult? Crit Care Med 1986; 14:755-56 Kubota Y, Toyoda Y, Kubota H, Asada A. Selective bronchial suctioning. Chest 1990; 97:1279 Schellinger RR. The len~h of the airway to the bifurcation of the trachea. Anesthesiology 1974; 25: 169-72 Wells AL, Wells TR, Landing BH, Cruz B, Galvis DA. Short trachea, a hazard in tracheal intubation of neonates and infants: syndromal associations. Anesthesiolof:O' 1989; 71 :367-73
6 Zwillich C~ Pierson D}, Crea~h CE, Sutton FD, Schatz E,
7
8 9
10
Petty TL. Complieations of assisted ventilation. Am J Med 1974; 57:161-70 Stauffer JL, Olson DE, Petty TL. Complieations and consequences of endotracheal intubation and traeheotomy. Am J Med 1981; 70:65-76 Owen RL, Cheney FW Endotracheal intubation: a preventahle (,'()mplication. Anesthesiology 1987; 67:255-57 Pollard BJ, Junius F. Accidental intubation of the esophagus. Anaesth Intens Care 1980; 183-86 Conrardy PA, Goodman LR, Lain~e F, Singer MM. Alteration of endotracheal tube position. Crit Care Med 1976; 4:8-12
To the Editor: Brunei et al (Chest 1989; 96:1043) are to be eon~ratulated for again bringing attention to the fact that auscultation of the chest is a poor diagnostic modality for unintentional endobronchial intubation. Their data is eonsistent with that of Heinonen (Lancet 1969:850), who showed x-ray evidenee of endohronchial intubation in 25 of 49 patients who had had an endotracheal tube withdrawn from a position of no left lun~ breath sounds to a point of supposed bilateral breath sounds. We do wish to comment, however, that Bnlnel et aI's 6ndin~ that endobronehial intuhation occurred in females with endotracheal tubes taped at 21 em at the teeth was because they did not take the patient's hei~ht into consideration when taping the tube. We (Owen and Chene}~ Anesthesiology 1987; 67:255) found no x-ray evidence of endobronchial intubation in a prospeetive study of 578 critically ill patients usin~ the eriteria of Communications to the Editor
t!'ill be published liS space lind prioritit's penn it. TIl(' C011l1nents should not l~xceed .3.50 word~ in l('ngth. with a TJulxi,nu,n of fi()(· njen'nces; one fifI,un' or table can hi' printl·d. f:xc{'l'tions 11Uly occur undi'r particular circu,nstances. Contributions 11Wy includlJ. co,nl1U'nts on articles published in this periodical, or thl'y TTUlY bl' reports oj unique educational character. ST)('cific 1)(~lission to ,mblish shoultl be cited in a cov(~ring left('r or 11l'l'endl·d as a postscript.
of an ET moved from 0.7 to 1.9 cm dependin~ upon head position, and as much as 5.2 cm with extension from a neutral position. Our data aJ.tree with these observations. Bnlnel et al noted that centimeter markings of ET is not reliable, but we eannot a~ree. Finally, we should like to inquire about the accuracy of the numbers "10 percent" and "78 percent (seven of nine)" in the discussion. Yukio Kubota, M.D.; Yoshiro Toyoda, M.D.; Hiroshi Kubota, M.D., and Yoshio Yanwsaki, M.D., Osaka Kohseinenkin Hospital, Osaka, japan
Confirmation of Endotracheal Tube Positioning UJ the Editor:
\Ve read with interest the re<..'ent article on, "Con6rmation of Endotracheal Tube Positioning," by Bnlnel et al (Chest 1989; 96:1043-45). Confirmation of proper endotracheal tube (ET) positionin~ is important for prevention of complications such as inadvertent endobronchial intubation (EBI) and accidental extubation; also for successful selective bronchial suctioning. 1-3 We have studied placement of the ET in more than several thousand patients by means of deliberate unilateral EBI, chest auscultation, cuff ballottement in the suprasternal notch and chest roentgenographic study. Usin~ these maneuvers, we have not encountered the abovementioned complications or esopha~eal intubation. Therefore, we would like to (,'omment by citin~ our experience. \Ve found that the distan(,'e from the upper incisor teeth to the carina in women was shorter than in men.· Thus, EBI may be more common in women. In addition, a congenital short trachea, althou~h a rare occurence, should be (,'()nsidered in this connection. 5 BruneI et aI noted that 60 per(,-ent (six of ten) of main-stem bronchial intubations occurred despite the presence of equal breath sounds on auscultation. We had the same experience in our earlier studies some ten years ago. \Ve found that breath sounds could be heard over the (,'()ntralateral lung field unless the ET fit snugly, the main-stem bronchus or the bronchus completely sealed by the cuff. These observations were substantiated both by auscultation and chest roentgenograms, and are also easily proven in a lung or tracheo-bronchial model. Bnlnel et al and others6-1i did not consider the matter of cuff inRation or leakage of gas around it. Bnlnel et al noted that breath sounds may be more readily transmitted to the opposite side and cited Owen's article;" Owen in turn referenced Pollard's article. 9Neither ofthese authors addressed the matter of gas leakage. Incidentally, Pollard's article described esophageal intubation, not EBI.9 We found that breath sounds could he heard to a lesser extent over the lung field of the non-intubated side between the midclavicular line and sternal edge at the level of first and second rihs, and inaudible at the level of the fourth and fifth ribs. Also, breath sounds were totally absent at the midaxillary line of the opposite side if gas leakage was not present. The eventual site of placement of an ET is affected by the following: head position (hyperextended, neutral or flexed) when measurements are performed; fixation of the ET at the level of the lower or upper lip, or at the (,-enter or angle of the mouth; dental eonditions, edentulous or not. lb quote BruneI: "The head is usually placed in a sniffin~ position during oral ET insertion," but they did not describe head position when measurements were made and chest roent~eno~rams taken. Conrardy et al lO reported that the tip
1306
_
Reprint requests: Dr. Kubota, Chie.f Department of Anesthesia,
Osaka Kohseinenkin Hospital 4-2-78 Fuku.vhima-ku, Osaka, japan 553 REFERENCES
2
3 4
5
Kubota Y, Magarjbuchi T, Toyoda Y, Murakawa M, Urabe N, Asada A, et al. Selective bronchial suctionin~ in the adult using a curved-tipped catheter with a ~lide mark. Crit Care Med 1982; 10:767-69 Kubota Y, Toyoda Y, Kubota H, Sawada S, Asada A, Sasai S, et al. Is a strai~t catheter ne<..-essary for selective bronchial suetioning in the adult? Crit Care Med 1986; 14:755-56 Kubota Y, Toyoda Y, Kubota H, Asada A. Selective bronchial suctioning. Chest 1990; 97:1279 Schellinger RR. The len~h of the airway to the bifurcation of the trachea. Anesthesiology 1974; 25: 169-72 Wells AL, Wells TR, Landing BH, Cruz B, Galvis DA. Short trachea, a hazard in tracheal intubation of neonates and infants: syndromal associations. Anesthesiolof:O' 1989; 71 :367-73
6 Zwillich C~ Pierson D}, Crea~h CE, Sutton FD, Schatz E,
7
8 9
10
Petty TL. Complieations of assisted ventilation. Am J Med 1974; 57:161-70 Stauffer JL, Olson DE, Petty TL. Complieations and consequences of endotracheal intubation and traeheotomy. Am J Med 1981; 70:65-76 Owen RL, Cheney FW Endotracheal intubation: a preventahle (,'()mplication. Anesthesiology 1987; 67:255-57 Pollard BJ, Junius F. Accidental intubation of the esophagus. Anaesth Intens Care 1980; 183-86 Conrardy PA, Goodman LR, Lain~e F, Singer MM. Alteration of endotracheal tube position. Crit Care Med 1976; 4:8-12
To the Editor: Brunei et al (Chest 1989; 96:1043) are to be eon~ratulated for again bringing attention to the fact that auscultation of the chest is a poor diagnostic modality for unintentional endobronchial intubation. Their data is eonsistent with that of Heinonen (Lancet 1969:850), who showed x-ray evidenee of endohronchial intubation in 25 of 49 patients who had had an endotracheal tube withdrawn from a position of no left lun~ breath sounds to a point of supposed bilateral breath sounds. We do wish to comment, however, that Bnlnel et aI's 6ndin~ that endobronehial intuhation occurred in females with endotracheal tubes taped at 21 em at the teeth was because they did not take the patient's hei~ht into consideration when taping the tube. We (Owen and Chene}~ Anesthesiology 1987; 67:255) found no x-ray evidence of endobronchial intubation in a prospeetive study of 578 critically ill patients usin~ the eriteria of Communications to the Editor