title: Tracheal palpation to assess endotracheal tube depth: an exploratory study.
abstract: OBJECTIVE
  Correct placement of the endotracheal tube (ETT) occurs when the distal tip is in mid-trachea. This study compares two techniques used to place the ETT at the correct depth during intubation: tracheal palpation vs placement at a fixed depth at the patient's teeth.
  
  
  METHODS
  With approval of the Research Ethics Board, we recruited American Society of Anesthesiologists physical status I-II patients scheduled for elective surgery with tracheal intubation. Clinicians performing the tracheal intubations were asked to "advance the tube slowly once the tip is through the cords". An investigator palpated the patient's trachea with three fingers spread over the trachea from the larynx to the sternal notch. When the ETT tip was felt in the sternal notch, the ETT was immobilized and its position was determined by fibreoptic bronchoscopy. The position of the ETT tip was compared with our hospital standard, which is a depth at the incisors or gums of 23 cm for men and 21 cm for women. The primary outcome was the incidence of correct placement. Correct placement of the ETT was defined as a tip > 2.5 cm from the carina and > 3.5 cm below the vocal cords.
  
  
  RESULTS
  Movement of the ETT tip was readily palpable in 77 of 92 patients studied, and bronchoscopy was performed in 85 patients. Placement by tracheal palpation resulted in more correct placements (71 [77%]; 95% confidence interval [CI] 74 to 81) than hospital standard depth at the incisors or gums (57 [61%]; 95% CI 58 to 66) (P = 0.037). The mean (SD) placement of the ETT tip in palpable subjects was 4.1 (1.7) cm above the carina, 1.9 cm (1.5-2.3 cm) below the ideal mid-tracheal position.
  
  
  CONCLUSIONS
  Tracheal palpation requires no special equipment, takes only a few seconds to perform, and may improve ETT placement at the correct depth. Further studies are warranted.
authors.affiliation: Department of Anesthesia, RUH, University of Saskatchewan, 103 Hospital Dr., Saskatoon, SK, S7N 0W8, Canada, bill.mckay@usask.ca.
authors.forename: William P
authors.initials: WP
authors.lastname: McKay
authors.forename: Jim
authors.initials: J
authors.lastname: Klonarakis
authors.forename: Vladko
authors.initials: V
authors.lastname: Pelivanov
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: O'Brien
authors.forename: Chris
authors.initials: C
authors.lastname: Plewes
mesh_terms: D000328:Adult; D000368:Aged; D001999:Bronchoscopy / Q000379:methods; D003430:Cross-Sectional Studies; D017558:Elective Surgical Procedures / Q000379:methods; D005260:Female; D005336:Fiber Optic Technology; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010173:Palpation / Q000379:methods*; D014132:Trachea