title: Assessment of three placement techniques for individualized positioning of the tip of the tracheal tube in children under the age of 4 years.
abstract: BACKGROUND
  Accurate positioning of the tip of the tracheal tube (tube tip) is challenging in young children. Prevalent clinical methods include placement of intubation depth marks, palpation of the tube cuff in the suprasternal notch, or deliberate mainstem intubation with subsequent withdrawal. To compare the predictability of tube tip positions, variability of the resulting positions in relation to the carina was determined applying the three techniques in each patient.
  
  
  METHODS
  In 68 healthy children aged ≤4 years, intubation was performed with an age-adapted, high-volume low-pressure cuffed tube adjusting the imprinted depth mark to the level of the vocal cords. The tube tip-to-carina distance was measured endoscopically. Thereafter, placements using (I) cuff palpation in the suprasternal notch and (II) auscultation to determine change in breath sounds during withdrawal after bronchial mainstem intubation were completed in random order.
  
  
  RESULTS
  Tube tip position above the carina was higher when using depth marks (mean = 36.8 mm) compared with cuff palpation in the suprasternal notch (mean = 19.0 mm). Variability, expressed as sd, was lowest with the mainstem intubation technique (5.2 mm) followed by the cuff palpation (7.4 mm) and the depth mark technique (11.2 mm) (P < 0.005).
  
  
  CONCLUSIONS
  Auscultation after deliberate mainstem intubation and cuff palpation resulted in a tube tip position above the carina that was shorter and more predictable than placement of the tube using depth markings.
authors.affiliation: Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
authors.forename: Jens
authors.initials: J
authors.lastname: Moll
authors.forename: Thomas O
authors.initials: TO
authors.lastname: Erb
authors.forename: Franz J
authors.initials: FJ
authors.lastname: Frei
mesh_terms: D059925:Anatomic Landmarks; D001314:Auscultation; D002675:Child, Preschool; D045422:Continuous Positive Airway Pressure; D005260:Female; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal / Q000379:methods*; D020704:Laryngoscopes; D008297:Male; D010173:Palpation; D011229:Preanesthetic Medication; D014132:Trachea / Q000033:anatomy & histology; D014827:Vocal Cords / Q000502:physiology
keywords: airway; cuff; endotracheal; pediatric; positioning; tube