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Factors associated with endotracheal tube malposition among pediatric patients with heart disease: a cross-sectional analytical study.


Karenne  N. Somera,
Charito C. Delos Santos,

Related Institution

Pediatric Pulmonary Medicine Section - Philippine Heart Center

Publication Information

Publication Type
Research Project
January 1-December 31, 2020


Background: Several guidelines and formula for endotracheal tube depth insertion are being studied and used. These suggested formulas in computation for the endotracheal tube (ETT) size and depth are based on age, weight and height of those with normal growth and mostly of the Western population. These may not be applicable for those children with growth impairment in patients with cardiac diseases. Investigation of the incidence of inappropriate ETT size and ETT malposition is important to lessen pulmonary complications in these population.

Method: This is a Cross-sectional analytical study approved by the Institutional Review Board of the Philippine Heart Center. Review of charts of pediatric patients, neonates up to 18 years of age with heart disease, who has undergone endotracheal intubation between April 1, 2017 and December 31, 2019 at the Philippine Heart Center was done. Age, gender, nutritional status, type of heart disease, setting of intubation, formula in computing for the ETT depth, and complications were all obtained from the charts of the patient. The ETT size and actual ETT lip level were also obtained. The actual ETT placement was compared with the computed ETT depth to identify which guideline specific formula was used. ETT placement, measured in centimeters, seen in chest radiograph taken in neutral position right after intubation was also obtained from the record of the patients. The chest radiographs were evaluated by a single identified radiologist to prevent inter-reader variation.

Results: A total of 99 patients with Heart Disease who underwent endotracheal intubation were included with age ranging from 4 days to 18 years and mean age of 87.71 months (±14.04). There is male preponderance (60.6%). From the review of the post-intubation chest radiographs, 51.52% endotracheal tubes were in place and 48.48% were misplaced. The presence of malnutrition, in general was not a significant factor (p=0.52). However, from the different types of malnutrition, severe stunting (p=0.021) was a factor in the occurrence of malpositioned ETT. Patients with severe stunting, were 3.23 times more likely to have malpositioned ETT as compared to those with normal growth and to those with stunting. In the multivariate analysis, the use of guideline-specified formula was noted to be a significant factor in decreasing the likelihood of malpositioned ETT. Neonates who have been intubated and guided by the NRP formula were 96.87% less likely to have malpositioned endotracheal tube. For those belonging to older age group, the use of ID estimation and PALS formula were 75.33% and 70.88% less likely to have malpositioned endotracheal tubes, respectively. Wheezing or bronchospasm was the most common complication followed by atelectasis of the left lung. On the other hand, those 29 patients with high-lying endotracheal tubes, only 2 patients had unplanned extubation.

Conclusion: Endotracheal tube insertion is an important and life-saving emergency procedure. There are several guidelines and recommendations in proper endotracheal tube insertion. These recommended formulas should be further studied in the pediatric population with different growth patterns to decrease incidence of malpositoning and further complications.

Physical Location

LocationLocation CodeAvailable FormatAvailability
Philippine Heart Center Medical Library CRF.R.020.20 Fulltext Print Format

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