Tracheal Palpation of Sliding Cuff to Assess Endotracheal Tube Location in Trachea - A Randomized Controlled Trial

Introduction:

Correct endotracheal tube (ETT) placement is important. Proper ETT position is achieved when the distal tip is in mid-trachea with the head in neutral alignment. Unrecognized tube misplacement is an uncommon but significant cause of hypoxemia and death during general anesthesia as well as in the care of critically ill patients.

Three types of malpositioning can occur: one outside the trachea (esophageal), and two within the trachea: too shallow, or too deep (endobronchial). Esophageal intubation results in hypoxemia and inflation of the stomach. Too-shallow placement of the ETT can result in inadvertent extubation, especially with manipulation of head and neck. Endobronchial intubation occurs when the ETT is advanced into a mainstem bronchus, which results in hypoxia and the potential for barotrauma in the hyperventilated lung.

Confirmation of correct ETT placement is currently performed by several methods. In the operating room, simple measurement of the length of the tube at the corner of the mouth using marks on the ETT is the usual method (Measurement Method: MM; 21cm at the teeth for women; 23cm for men). It is simple and rapid, but not reliable. One study attempted to improve on this by using anatomical landmarks to determine ETT tube length as measured at the mouth. It enabled a reduction in the incidence of too-deep placement of the ETT from 58.8% to 24%. Measurement of these landmarks is sufficiently inconvenient that it is not widely practised.

Cuff ballottement at the level of the suprasternal notch is a technique that has been studied with cuffed tubes in adults. Ballottement involves moving the fingers in a radial axis of the ETT in order to compress and release the cuff, while feeling and watching the corresponding movement of the pilot balloon. Studies to date of ballottement do not comment on its ability to prevent esophageal intubation.