Impact of changes in head position during head and neck surgery on the depth of tracheal tube intubation in anesthetized children

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Abstract

Background

The classic formula has been used to estimate the depth of tracheal tube intubation in children for decades. However, it is unclear whether this formula is applicable when the head and neck position changes intraoperatively.

Methods

We prospectively reviewed the data of 172 well-developed children aged 2–12 years (64.0% boys) who underwent head and neck surgery under general anesthesia. The distances from the tracheal carina to the endotracheal tube tip (CT), from the superior margin of the endotracheal tube tip to the vocal cord posterior commissure (CV), and from the tracheal carina to the posterior vocal commissure (TV) were measured in the sniffing position (maximum), neutral head, and maximal head flexion positions.

Results

Average CT and CV in the neutral head position were 4.33 cm and 10.4 cm, respectively. They increased to 5.43 cm and 11.3 cm, respectively, in the sniffing position, and to 3.39 cm and 9.59 cm, respectively, in the maximal flexion position (all P-values < 0.001). TV remained unchanged and was only dependent on age. After stratifying patients by age, similar results were observed with other distances. CT and CV increased by 1.099 cm and 0.909 cm, respectively, when head position changed from neutral head to sniffing position, and decreased by 0.947 cm and 0.838 cm, respectively, when head position changed from neutral head to maximal flexion.

Conclusion

Change in head position can influence the depth of tracheal tube intubation. Therefore, the estimated depth should be corrected according to the surgical head position.

Related collections

Most cited references 16

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[Height and weight standardized growth charts for Chinese children and adolescents aged 0 to 18 years].

Cheng Ji, Xin-Nan Zong, Yan-Hui Li … (2009)

To construct the height and weight growth charts for Chinese children and adolescents from birth to 18 years for both clinical and preventive health care uses. Data from two national representative cross-sectional surveys which were The National Growth Survey of Children under 7 years in the Nine Cities of China in 2005 and The Physical Fitness and Health Surveillance of Chinese School Students in 2005. The data from 94,302 urban healthy children were used to set up the database of length/height (length was measured for children under 3 years) and weight. The LMS method was used to smooth the growth curves, with estimates of L, M, and S parameters, values of percentile and Z-score curves which were required were calculated, and then generated standardized growth charts. The 3rd, 10th, 25th, 50th, 75th, 90th, 97th smoothed percentiles curves and -3, -2, -1, 0, +1, +2, +3 Z-scores curves of weight-for-age, length/height-for-age for boys and girls aged 0-18 years were made out respectively. Comparison with the new WHO growth charts and 2000 CDC growth charts for the United States, the results showed that there was some big difference in weight and height among the three growth charts. For boys under 15 years of age and girls under 13 years of age, the China curves are slightly higher than WHO and CDC curves, but after those ages, the China curves fall behind and the difference became larger as age progresses. At the age of 18 years, the Chinese children are 3.5 cm shorter in boys and 2.5 cm shorter in girls as compared with the U. S. children. The difference in weights are very large for the school children, especially in girls. The weight of Chinese boys was 5.9 kg less than that of the U. S. boys at 18 years, and the difference was much bigger in girls, the weight of U.S. girls between 8 to 18 years was 4.1-20.5 kg more than that of Chinese girls at the same age range. The new growth charts of height and weight were based on national survey data and therefore are recommended as the China national growth standards for use in pediatric clinics and public health service. Application of the charts will promote child growth monitoring, discovering early growth disorder, and will be useful to diagnosis of diseases and assessment of therapeutic effects.

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Appropriate placement of intubation depth marks in a new cuffed paediatric tracheal tube.

Marjan Weiss, A Dullenkopf, Philipp Gerber (2004)

The aim of this study was to evaluate the appropriateness of intubation depth marks on the new Microcuff paediatric tracheal tube. With local Institutional Ethics Committee approval and informed parental consent, we included patients from birth (weighing > or =3 kg) to 16 yr who were undergoing general anaesthesia requiring orotracheal intubation. Tracheal intubation was performed using direct laryngoscopy, the intubation depth mark was placed between the vocal cords, and the tube was taped to the lateral corner of the mouth. The distance between the tube tip and the tracheal carina was assessed by flexible bronchoscopy with the patients in supine, and their head in neutral positions. Tube sizes were selected according to the formula: internal diameter (ID; mm)=(age/4)+3.5 in children > or =2 yr. In full-term newborns (> or =3 kg) to less than 1 yr ID 3.0 mm tubes were used and in children from 1 to less than 2 yr ID 3.5 mm tubes were used. Endoscopic examination was performed in 50 size ID 3.0 mm tubes, and in 25 tubes of each tube size from ID 3.5 to 7.0 mm. Tracheal length and percentage of the trachea to which the tube tip was advanced were calculated. 250 patients were studied (105 girls, 145 boys). The distance from the tube tip to the carina ranged from 1.4 cm in a 2-month-old infant (ID 3.0 mm) to 7.7 cm in a 14-yr-old boy (ID 7.0 mm). Mean tube insertion into the trachea was 53.2% (6.3) of tracheal length with a minimum of 40% and a maximum of 67.6%. The insertion depth marks of the new Microcuff paediatric tracheal tube allow adequate placing of the tracheal tube with a cuff-free subglottic zone and without the risk for endobronchial intubation in children from birth to adolescence.

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Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment.

W Knirsch, M Tomaske, Mark L. Weiss … (2006)

Aims of this study were to assess the maximum displacement of tracheal tube tip during head-neck movement in children, and to evaluate the appropriateness of the intubation depth marks on the Microcuff Paediatric Endotracheal Tube regarding the risk of inadvertent extubation and endobronchial intubation. We studied children, aged from birth to adolescence, undergoing cardiac catheterization. The patients' tracheas were orally intubated and the tracheal tubes positioned with the intubation depth mark at the level of the vocal cords. The tracheal tube tip-to-carina distances were fluoroscopically assessed with the patient supine and the head-neck in 30 degrees flexion, 0 degrees neutral position and 30 degrees extension. One hundred children aged between 0.02 and 16.4 yr (median 5.1 yr) were studied. Maximum tracheal tube-tip displacement after head-neck 30 degrees extension and 30 degrees flexion demonstrated a linear relationship to age [maximal upward tube movement (mm)=0 0.71 x age (yr)+9.9 (R(2)=0.893); maximal downward tube movement (mm)=0.83 x age (yr)+9.3 (R(2)=0.949)]. Maximal tracheal tube-tip downward displacement because of head-neck flexion was more pronounced than upward displacement because of head-neck extension. The intubation depth marks were appropriate to avoid inadvertent tracheal extubation and endobronchial intubation during head-neck movement in all patients. However, during head-neck extension the tracheal tube cuff may become positioned in the subglottic region and should be re-adjusted when the patient remains in this position for a longer time.

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Author and article information

Contributors

Huan Zhang: btchmz@163.com

Journal

Journal ID (nlm-ta): BMC Anesthesiol

Journal ID (iso-abbrev): BMC Anesthesiol

Title: BMC Anesthesiology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2253

Publication date (Electronic): 24 May 2020

Publication date PMC-release: 24 May 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 124

Affiliations

Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168, LiTang Road, ChangPing District, Beijing, China

Article

Publisher ID: 1033

DOI: 10.1186/s12871-020-01033-7

PMC ID: 7245884

PubMed ID: 32448244

SO-VID: 0f4e3392-bf2c-4ad3-8da0-ed887bb7a40d

License:

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