Can Intubation Be Improved with Endotracheal Tubes Marked with a Color Scale? Randomized Controlled Study

Abstract

Objective This study aimed to assess if a color scale in the endotracheal tube (ETT) can help operators to correctly select the size and depth of placement of the ETT and decrease the time required to complete the procedure and compared with the usual numeric ETT scale in a mannequin model.

Study Design The study was conducted in eight centers. Each size of the ETT was identified with a different color. The experimental ETTs had two different colored areas, one for the mouthpiece and another to identify where the ETT should be taped above the lip (an area of 1 cm. The operators were trained as part of the protocol using an instructional video. Four clinical scenarios requiring endotracheal intubation were designed and randomly assigned. Each operator had to select the size and depth of ETT based on the birth weight (BW), and then had to perform four intubations.

Results A total of 108 operators performed 432 intubations. No differences were found in the correct placement and selection of the ETT. Median time (in seconds) required for intubation using numeric versus experimental tube was: for ETT Ø NRP (Neonatal Resuscitation Program) 2.5, 11.5 versus 8 (p < 0.001), ETT Ø 3, 12 versus 10 (p < 0.001), ETT Ø 3.5, 15.5 versus12 (p = 0.003), ETT Ø 4, 12 versus11 (p = 0.019).

Conclusion No significant difference was observed in the selection and correct placement of the ETT. However, the intubation time was significantly shorter using the experimental ETT. This device could improve the effectiveness of intubation by reducing the time needed to properly place the ETT at mid trachea.

Key Points

• It is an innovative intervention to try to solve a great inconvenience of daily practice.

• The study also raises the difficulty in maintaining the ability of endotracheal intubation.

• It proposes a scale that ensures the correct location with a safe fixation zone.

Keywords

newborn - resuscitation - endotracheal intubation - error - fixation

What Is Known about This Topic

Neonatal intubation is a critical skill that seems to be difficult to acquire and that improves with practice. Misplacement of the ETT can lead to complications. To determine the depth of ETT insertion, different methods have been proposed based on weight, gestational age, and length. The NRP guidelines suggest the use of the Tochen rule based on BW which seems to be an accurate method in neonates weighing over 750 g. In smaller babies, its usefulness is less clear.

What This Study Adds

We propose the use of a new scale that establishes a safety zone, enabling strict confirmation of ETT position, while the newborn remains intubated.

Authors' Contributions

J.P.B., R.P.L., and N.E.V. conceptualized and designed the study, drafted the initial manuscript, and approved the final manuscript as submitted.

J.P.B., R.P.L., A.L.F., and N.E.V. performed the initial analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted.

A.A.C., R.M.S., and A.S.A. designed the data collection instruments and coordinated and supervised data collection at the participating sites, critically reviewed the manuscript, and approved the final manuscript as submitted.

Patent

The patent for this product is pending.

Publication History

Received: 25 April 2021

Accepted: 28 September 2021

Accepted Manuscript online:
30 September 2021

Article published online:
16 November 2021

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