Prediction of the mid-tracheal level using surface anatomical landmarks in adults: Clinical implication of endotracheal tube insertion depth

Endotracheal tube (ETT) should be placed at the optimal level to avoid single lung ventilation or accidental extubation. This study was performed to estimate the mid-tracheal level by using surface anatomical landmarks in adult patients. Neck computed tomography images of 329 adult patients between the ages of 16 and 79 years were reviewed. In the midline sagittal plane, the levels corresponding to the vocal cords, cricoid cartilage, suprasternal notch, manubriosternal junction, and carina were identified. The surface distances from the cricoid cartilage to the suprasternal notch ((ext)CC-SSN) and that from the suprasternal notch to the manubriosternal junction ((ext)SSN-MSJ) were measured. The relationship between mid-tracheal level and the surface distances was analyzed using Bland–Altman plot. The difference between the (ext)CC-SSN and the mid-tracheal level was −6.6 (12.5) mm, and the difference between the (ext)SSN-MSJ and the mid-tracheal level was −19.2 (6.1) mm. The difference between the (ext)CC-SSN and the mid-tracheal level was smaller in females compared with males [−1.7 (11.7) mm vs −12.8 (10.7) mm; P < 0.001]. The mid-tracheal level, which is helpful in planning the insertion depth of an ETT, can be predicted by the surface distance between the cricoid cartilage and suprasternal notch in adults, especially in females.