1995 OPEN FORUM Abstracts
Assessment Of Endotracheal Tube (Ett) Placement In Neonates Using A Fiberoptic Stylet
Thomas J. Kallstrom R.R.T. and Robert L. Chatburn R.R.T. Rainbow Babies and Childrens Hospital, Cleveland, OH.
This is a continuation of a pilot study (Respir Care 1994;39:1061) evaluating a lighted fiberoptic stylet (Infinity Fiberoptic Stylet, Fiberoptic Medical Products Inc.) for assessment of ETT placement. The purpose of the study was to determine if this alternative method could replace routine chest x-ray (CXR) assessment. METHOD: Intubated neonates in our NICU were entered into the study over a one year period (convenience sample). Within 60 minutes of CXR and before the results were known to the RCP an ETT placement evaluation was made using the lighted stylet. The tip of the stylet was advanced into the ETT to a pre-measured mark which placed it at the distal tip of the tube. If the light was visible through the skin at the suprasternal notch, the ETT was considered to be correctly placed. If the light was visible above the suprasternal notch, the ETT was judged to be too high and if the light disappeared after passing below the notch, the ETT was judged to be too low. The procedure lasted< = 10 seconds. SpO2 was measured before and after the procedure. Assessment of ETT placement using the fiberoptic stylet was evaluated with CXR as the standard (positive and negative predictive values).
Results: Data for 93 patients were collected by 16 RCPs. Weight range: 430-4100 grams; ETT size: 2.5-3.5 mm ID; age: 10 minutes to 2 months. Fifty patients were Caucasian, 37 were not, and 8 were unknown. Data analysis is illustrated in the figure below. Seventy eight out of 93 (84%) assessments agreed with the CXR. The positive predictive value of fiberoptic assessment was 86%; negative predictive value was 75%. Mean SpO2 before and after procedure were identical. There was no indication that the fiberoptic assessment errors were made more frequently by specific RCPs. The assessment error occurred randomly over time indicating no learning curve effect. Errors in assessment linked to race or weight were not evident. The average weight of correctly assessed infants was 1,726g vs 1573g for the group incorrectly assessed. ETT size distribution for correctly assessed patients was 2.5mm: 29%, 3.0mm: 50%, 3.5mm: 21% vs 2.5mm: 24%, 3.0mm: 56%, 3.5mm: 18% for incorrectly assessed patients. EXPERIENCE: The lighted stylet is a portable and convenient tool. It can be used by the RCP without the delay that waiting for a CXR may take. CONCLUSION: The stylet does not appear to be accurate enough at determining ETT position to replace CXR, particularly since confirming proper placement is not as desirable as identifying improper placement. No clear subset of the population could be identified for which negative predictive value was acceptable. The resolution of assessment seems no better than 1 cm, which is relatively large compared to the length of the trachea for this population of infants. This observation may explain our findings.
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