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PEDIATRIC ANESTHESIA

Auscultation of Bilateral Breath Sounds Does Not Rule Out Endobronchial Intubation in Children

Susan T. Verghese, MD^*, Raafat S. Hannallah, MD^*, Michael C. Slack, MD, Russell R. Cross, MD, and Kantilal M. Patel, PhD

Departments of *Anesthesiology, Pediatric Cardiology, and Pediatrics, Children’s National Medical Center and George Washington University Medical Center, Washington, DC

Address correspondence and reprint requests to Susan Verghese, MD, Department of Anesthesiology, Children’s National Medical Center, 111 Michigan Ave., N.W., Washington, DC 20010. Address e-mail to sverghes{at}cnmc.org

We performed orotracheal intubation in 153 consecutive pediatric patients undergoing cardiac catheterization. Auscultation of bilateral breath sounds was confirmed. By fluoroscopy, the tip of the endotracheal tube (ETT) was seen in the right mainstem bronchus in 18 patients (11.8%) and in a low position, defined as within 1 cm above the carina, in 29 patients (19.0%). All of the 18 patients with right mainstem intubation were children <120 mo of age, and 7 were infants <12 mo of age (Fisher’s exact test; P = 0.013). The age, weight, and ETT size for children who had endobronchial and low tracheal positions were significantly (P < 0.001) less than for those who had midtracheal positions. The failure to diagnose mainstem intubation by auscultation alone may be related to the use of the Murphy eye ETT, which reduces the reliability of chest auscultation in detecting endobronchial intubation. Suggested measures for preventing endobronchial intubation include maintaining increased awareness of the imperfection or lack of accuracy of the auscultatory method, assessing insertion depth by checking the length scale on the tube, and minimizing the patient’s head and neck movement after intubation. When extreme flexion or extension of the neck is expected after ETT insertion, the resultant change in ETT final position must be anticipated and taken into consideration when deciding on the depth of ETT insertion. This approach resulted in a decrease in improper tube positioning from 20% when the study was initiated to 7.1% in the last 98 patients.

IMPLICATIONS: Despite confirmation of correct endotracheal tube position by auscultation, fluoroscopy showed an endobronchial tube position in 11.8% of children positioned with their arms above their heads during cardiac catheterization procedures. This potential problem must be anticipated when deciding on the depth of tube insertion.

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