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Radiological validation of endotracheal tube insertion depth in prehospital emergency patients


Incorrect positioning of the endotracheal tube (ETT) within the airway after emergent intubation can result in serious complications. Accidental mainstem bronchus intubation is associated with contralateral atelectasis, tension pneumothorax, hypotension, and decreased survival. Conversely, failure to place the tube several centimeters beyond the vocal cords may result in inadvertent extubation, aspiration, pneumonia, or laryngeal spasm [1]. The aim of this study was to investigate the occurrence of ETT malpositioning after emergency intubation in the out-of-hospital setting.


A retrospective study of a 5-year time period, using records of 1,081 patients admitted to the trauma emergency room (ER) at a university hospital. Within 30 minutes after admission, a chest X-ray or whole-body CT scan was routinely performed in intubated patients to determine the tube–tip–carina relationship.


Sixteen out of 1,081 patients died immediately after admission to the trauma ER and were not further radiologically diagnosed. Of the surviving 1,065 patients, 346 (32.5%) were female and 719 (67.5%) male. In the group of 488 intubated patients, 346 (70.9%) were correctly intubated, 89 (18.2%) were not correctly intubated – herein were 64 patients (14.7%) intubated with tip–carina distance <2 cm, and 25 patients (5.7%) were endobronchially intubated. Chest X-ray scans were not available for 53 patients (10.9%). Detailed data on ETT placement were available in 435 patients; 346 (79.5%) with correct ETT placement, 89 (20.5%) with incorrect ETT placement. None of the patients displayed an esophageal or pharyngeal intubation (0%). Of 435 patients, 324 had been intubated preclinically on scene – 254 (78.4%) were correctly intubated, 70 (21.6%) were not correctly intubated.


This study clearly shows that ETT misplacement in emergency patients is still a serious problem with an incidence of 21.6% in our study, of which 5.7% were endobronchially intubated. We conclude that the skill level of the operator may be key in determining efficacy of endotracheal intubation. Based on our findings, all efforts should be made to verify the tube position with immediate radiographic confirmation after admission to the ER.


  1. Owen RL, Cheney FW: Endobronchial intubation: a preventable complication. Anesthesiology 1987, 67: 255-257. 10.1097/00000542-198708000-00019

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Maybauer, D., Maybauer, M., Wolff, H. et al. Radiological validation of endotracheal tube insertion depth in prehospital emergency patients. Crit Care 13 (Suppl 1), P3 (2009).

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  • Endotracheal Tube
  • Emergency Patient
  • Insertion Depth
  • Tension Pneumothorax
  • Emergency Intubation