2004 OPEN FORUM Abstracts
ENDOTRACHEAL TUBE CHANGES IN NEWBORNS AND INFANTS; DON’T BELIEVE EVERYTHING YOU SEE.
Robert
Posen M.D., Bernard Halabi RRT,RCP, John Cefaratt B.S.,RRT,NPS Neonatal
ICU - Huntington Memorial Hospital Pasadena, California
Background:
Endotracheal tube placement in newborns and infants is usually
confirmed by chest x-ray. Normally the ET-tube tip should be between
T-2 and T-3. Often times tube placement is misinterpreted and ordered
to be repositioned a measured distance to correct a perceived
error.This is done with potential risks to the patients mucosa and
face along with inadvertent extubation.
Method: A
retrospective chart review identified ten patients, randomly
selected, with a total of 408 ventilator days. Within that time
period ET-tubes were moved in and out 113 times. A tracking form was
developed which required the RT to be present at the bedside and to
fill in a column of the form with each x-ray, thus verifying correct
neutral position of the head and body as well as tube placement by
lip level. After implementing the tracking form a second random chart
review was initiated.
Results: To date five patients have been
reviewed with 27 ventilator days thus far. Of those 27 days the
ET-tubes had been repositioned four times. Before the form was
instituted there was a27.2% change rate/day. After the form there has
been a 14.8% change rate. This is a 12.9% drop in position changes
per ventilator.
Experience: It has been noted that even though
RTs are present in the NICU they may not always be present at the
bedside for the x-ray. Having the form as a monitor to insure the
best placement of the patient for x-ray will minimize erroneous
reports of tube placement. Many patients have had their ETtube moved
in and out multiple times in the course of their ventilatory care.
Often times unnecessarily if the head and body had been properly
placed or taken into consideration when the film was read.
Conclusion: With the implementation of a tracking form RTs are
more aware of patient body position, ETtube securing point and head
and chin position for x-rays. If a tube appears out of the acceptable
range by chest x-ray, the tracking form will reveal a plausible
explanation that would negate reposition-ing the tube, in addition a
closer inspection of the chest x-ray itself should help identify
position errors i.e. body rotation, neck flexed or extended, foreign
objects under the patient. Minimizing tube repositioning decreases
risks of mucosal damage and facial skin breakdown.