![]() ![]() For this reason, the current standard is to confirm tracheal placement using end-tidal CO2. In one series of esophageal intubation cases, almost half documented auscultation of breath sounds ( Salem 2001). For example, auscultation isn't even reliable enough to confirm that the ETT is in the trachea rather than the esophagus. Myth #2: Auscultation will reliably detect right mainstem intubation.Īuscultation is notoriously inaccurate for determining ETT location. Patients of Asian ethnicity have a higher risk of mainstem intubation when using this rule ( Ong 1996). The 23/21 rule was developed in the United States, but has failed validation among more diverse populations. This rule fails in the following situations: Thus, the 23/21 rule is a crude approximation based on the fact that men, on average, are taller than women. In multivariable models including height and gender, gender doesn't add any independent information ( Varshney 2011). The strongest determinant of ETT depth is height. According to the 23/21 rule, the man's ETT should be placed deeper than the woman's ETT. One patient is a five-foot tall man, the other is a six-foot tall woman. Imagine two patients requiring intubation. This is derived from a study of 83 adults in Cincinnati, USA ( Roberts 1995).ĭispelling this myth may be accomplished with a simple thought experiment. Myth #1: The endotracheal tube should be placed at 23cm in men and 21cm in women (23/21 rule)Ī widely held belief is that the endotracheal tube (ETT) should be secured at 23cm for men and 21cm for women. Rather, this may result from a systemic flaw in our approach to determining endotracheal tube depth. The physicians involved in these cases aren’t bad doctors. I’ve seen this error pattern several times. However, in a critically ill patient with fragile lungs, it can be. Mainstem intubation usually isn’t this catastrophic. Next: hypotension, and maybe cardiac arrest. With more bagging, this progresses to a tension pneumothorax. Unfortunately, all this does is over-distend the right lung, which pops: pneumothorax. What is your natural response? You bag a bit harder and faster, trying to recruit some atelectatic lung. The left lung isn't being ventilated, so the patient starts to desaturate. The ICU is noisy, masking any difference in bilateral breath sounds. Unfortunately, your patient is small, so the tube ends up in the right mainstem bronchus. Fantastic! You secure the endotracheal tube at 22cm. You pre-oxygenate the patient and perform a beautiful intubation on the first attempt. Imagine that you are intubating a patient with ARDS. Introduction with a rare but recurrent error pattern Meanwhile, this is often the point when the patient's blood pressure and saturation nadir. There is a risk of relaxing and overlooking critical details. According to Napoleon, “the moment of greatest vulnerability is the instant immediately after victory.” In airway management, this instant occurs immediately after placement of the endotracheal tube. ![]()
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