Evaluation of Endotracheal Tube Depth in the Out-of-Hospital Setting

Introduction Endobronchial intubation is a known complication of endotracheal intubation with significant associated morbidity and a reported incidence of up to 15%. In the out-of-hospital setting, paramedics must rely on bedside techniques to confirm appropriate endotracheal tube (ETT) depth. The present real-world practices of paramedics have not been described in this regard. Methods A multi-point survey was distributed to paramedics within the state of Pennsylvania. Participants were scored on the basis of their use of techniques to confirm ETT depth with the highest sensitivity to exclude endobronchial intubation. Results Four-hundred nine (409) responses from 111 emergency medical services (EMS) agencies were recorded. Participants were found to evaluate endotracheal tube depth via auscultation of bilateral breath sounds (91.7% of participants), visualization of the endotracheal tube as it advances 1-2 cm beyond the vocal cords (82.9%), observation of symmetrical chest rise (80.0%), and by securing the ETT at 21 and 23 cm at the incisors for women and men (18.6%). Experienced paramedics were more likely to use the 21/23 cm rule (p=0.039). Participants did not employ the cumulative use of these techniques (p < 0.001) as per a method that has been previously described to exclude endobronchial intubation with 100% sensitivity. Conclusion These data suggest that paramedics are not presently employing the most sensitive techniques to exclude endobronchial intubation. An educational initiative and protocol update may be beneficial.