Hostname: page-component-848d4c4894-v5vhk Total loading time: 0 Render date: 2024-07-06T03:41:00.115Z Has data issue: false hasContentIssue false
  • English
  • Français

Evaluation of Manual Cuff Palpation to Confirm Proper Endotracheal Tube Depth

Published online by Cambridge University Press:  17 February 2017

David Ledrick ,
Michael Plewa ,
Kevin Casey ,
Jay Taylor  and
Nancy Buderer
David Ledrick*
Affiliation:
Emergency Medicine Residency Program, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
Michael Plewa
Affiliation:
Emergency Medicine Residency Program, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
Kevin Casey
Affiliation:
Emergency Medicine Residency Program, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
Jay Taylor
Affiliation:
Emergency Medicine Resident, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
Nancy Buderer
Affiliation:
Independent Consultant, Oak Harbor, Ohio, USA
*
David Ledrick, MD, 5862 Rock Hill Lane, Sylvania OH, 43560 USA, E-mail: ledrick@buckeye-express.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Introduction: In the prehospital setting, optimal endotracheal tube (ETT) depth may be approximated using the patient's sex or height, and assessed by auscultation. Even when using these methods, the ETTs still may be placed at inappropriate depths.

Problem: This study assessed the inter-rater reliability and accuracy of manual cuff palpation (ballottement) at excluding an improperly placed ETT depth in adult patients.

Methods: This is a prospective, observational, pilot study in a convenience sample of adults recently intubated in the prehospital, medical floor, intensive care unit, or emergency department settings of an urban, teaching hospital. Two physician participants separately performed ballottement on each intubated subject and rated the ballottement as none, weak, or strong prior to assessment of appropriate depth using a chest radiograph (CXR). Results were compared for simple agreement and compared to the CXR to estimate accuracy.

Results: Of 163 patients, 27 (17%) had an inappropriate ETT depth. Physician assessments of ballottement agreed in 79% of patients (95% CI = 72-85%). Chest radiograph assessment found the ETT in the “strong” ballottement group properly placed in 93%, as compared to 77% in the “weak”, and 42% in the “none” groups. Combining “weak” and “strong” ballottement, the sensitivity was 96% (95% CI = 93–100%), specificity was 26% (95% CI = 9–43%), and accuracy was 85% (95% CI = 79–90%).

Conclusions: Manual cuff palpation is a simple and reproducible technique that is sensitive, but nonspecific, in identifying intubations of appropriate depth.

Keywords

airwayballottementchest x-rayendotracheal tubeintubationmanual cuff palpationprehospital settingreliability
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 23 , Issue 3 , June 2008 , pp. 270 - 274
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Jemmett, ME, Kendal, KM, Fourre, MW, Burton, JH: Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med 2003; 10: 961–965.CrossRefGoogle Scholar
2. Dronen, S, Chadwick, O, Nowak, R: Endotracheal tip position in the arrested patient. Ann Emerg Med 1982; ll: 116–117.CrossRefGoogle Scholar
3. Schwartz, DE, Lieberman, JA, Cohen, NH: Women are at greater risk than men for malpositioning of the endotracheal tube after emergent intubation. Crit Care Med 1994; 22: 1127–1131.CrossRefGoogle ScholarPubMed
4. Pollard, RJ, Lobato, EB: Endotracheal tube location verified reliably by cuff palpation. Anesth Analg 1995; 81; 135–138.Google ScholarPubMed
5. Techanivate, A, Kumwilaisak, K, Samranrean, S. Estimation of the proper length of orotracheal intubation by Chula formula. J Med Assoc Thai 2005; 88: 1838–1846.Google ScholarPubMed
6. Evron, S, Weisenberg, M, Harow, E, Khazin, V, Szmuk, P, Gavish, D, Ezri, T: Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements. J Clin Anesth 2007; 19: 15–19.CrossRefGoogle ScholarPubMed
7. Goodman, LR, Conrardy, PA, Laing, F, Singer, MM: Radiographic evaluation of endotracheal tube position. Am J Roentgenol 1976; 127: 433–434.CrossRefGoogle ScholarPubMed
8. Bednarek, FJ, Kuhns, LR: Endotracheal tube placement in infants determined by suprastemal palpation: a new technique. Pediatrics 1975; 56: 224–229.CrossRefGoogle Scholar
9. Pappas, JN, Goodman, PC: Predicting proper endotracheal tube placement in underexposed radiographs: Tangent line of the aortic knob. AJR 1999; 173: 1357–1359.CrossRefGoogle Scholar
10. Locker, GJ, Staudinger, T, Knapp, S, Burgmann, H, Laczika, KF, Zimmerl, M, HŒrmann, M, Frass, MR: Assessment of the proper depth of endotracheal tube placement with the Trachlight. J Clin Anesth 1998; 10: 389–393 CrossRefGoogle ScholarPubMed
11. Sugiyama, K, Yokoyama, K: Reliability of auscultation of bilateral breath sounds in confirming endobronchial tube position. Anesthesiobgy 1995; 83:1373.CrossRefGoogle Scholar
12. Roberts, JR, Spadafora, M, Cone, DC: Proper depth placement of oral endotracheal in adults prior to radiographic confirmation. Acad Emerg Med 1995; 2: 20–24.CrossRefGoogle ScholarPubMed
13. Reed, DB, Clinton, JE: Proper depth of placement of oral endotracheal tubes in adults prior to radiographic confirmation. Acad Emerg Med 1997; 4: 1111–1114.CrossRefGoogle Scholar
14. Shellinger, RR: The length of the airway to the bifurcation of the trachea. Anesthesiology 1964; 25: 169–172.CrossRefGoogle Scholar
15. Cherng, CH, Wong, CS, Hsu, CH, Ho, ST: Airway length in adults: estimation of the optimal endotracheal tube length for orotracheal intubation. J Clin Anesth 2002; 14: 271–274.CrossRefGoogle ScholarPubMed
16. Okuyama, M, Imai, M, Sugawara, K, Okuyama, A, Kemmotsu, O: [Finding appropriate tube position by the cuff palpation method in children] Masui 1995; 44: 845–848.Google ScholarPubMed
17. Goldman, JM, Armstrong, JP, Vaught, LE, Daniel, LC: A new method for identifying the depth of insertion of tracheal tubes. Bionted Sci Instrum 1995; 31: 225–228.Google ScholarPubMed
18. Pattnaik, SK, Bodra, R: Ballotability of cuff to confirm the correct intratracheal position of the endotracheal tube in the intensive care unit. Eur J Anaesthesiol 2000; 17: 587–590.CrossRefGoogle ScholarPubMed
19. Jain, A, Finer, NN, Hilton, S, Rich, W: A randomized trial of suprastemal palpation to determine endotracheal tube position in neonates. Resuscitation 2004; 60: 297–302.CrossRefGoogle Scholar
20. Stewart, RD, LaRosee, A, Kaplan, RM, Ilkhanipour, K: Correct positioning of an endotracheal tube using a flexible lighted stylet. Crit Care Med 1990; 18: 97–99.CrossRefGoogle ScholarPubMed
21. Sugiyama, K, Mietani, W, Hirota, Y, Matsuura, H: Displacement of the endotracheal tube caused by postural change: Evaluation by fibreoptic observation. Anaesth Pain Control Dent 1992; 1: 29–33.Google ScholarPubMed
22. Yap, SJ, Morris, RW, Pybus, DA: Alteration in endotracheal tube position during general anaesthesia. Anaesth Intens Care 1994; 22: 586–588.CrossRefGoogle ScholarPubMed