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Failure to confirm endotracheal tube placement in children can lead to hypoxia and death, warns Reneé Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at Cincinnati Medical Center. The Dallas-based American Heart Association (AHA) recommends the use of exhaled carbon dioxide (CO2) detectors with pediatric intubation to confirm endotracheal tube placement, she reports.
The exhaled CO2 detectors are recommended when the tube is initially inserted because of the potentially devastating consequences from unrecognized esophageal intubation and/or dislodged endotracheal tubes, stresses Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA.
Here are things to consider when confirming tube placement:
• Don’t rely on traditional assessments. It might be difficult to confirm correct endotracheal tube placement by relying solely on traditional assessments, such as chest wall expansion, color, and breath sounds, says Wolff.
• Use continuous capnography or a colorimetric device. Exhaled CO2 can be measured using continuous capnography or a colorimetric device, says Wolff. "Continuous capnography provides a continuous waveform showing exhaled CO2," she explains. "This type of monitoring is most commonly used in intensive care units."
The colorimetric devise is a small, disposable plastic adapter available in pediatric and adult sizes, says Wolff. "It fits between the end of the tracheal tube and the bag-valve device. A color change indicates the presence of exhaled CO2,, she explains. Read the device after six ventilations because it takes approximately this number of ventilations to wash out the CO2 from the esophagus, Wolff adds. "Make sure to differentiate between tracheal intubation where CO2 should be detected, from esophageal intubation where CO2 should not be detected," she says.
In patients with pulseless arrest, the absence of exhaled CO2 might indicate that the tracheal tube is not in the trachea or the child is not exhaling enough CO2 to be measured because of decreased pulmonary blood flow, Wolff notes. Wolff stresses that exhaled CO2 devices will detect CO2 when the tracheal tube is improperly placed in the right main stem bronchus.
• Assess auscultation of breath sounds. Depending on the child’s size, breath sounds might be transmitted in both the chest and abdomen, says Holleran. "Breath sounds alone do not indicate tube placement," she notes.
• Use direct visualization when necessary. If there is any doubt regarding tube position, use direct visualization, says Wolff. "This method requires the use of a laryngoscope to verify that the tracheal tube is passed through the glottic opening," she explains. "Chest radiography and clinical assessment, including chest rise, color, and breath sounds, should also be used to confirm proper placement in addition to exhaled CO2."
• Confirm placement after transport. The AHA guidelines also recommend use of exhaled CO2 detectors to confirm that the tube has not been dislodged during transport, says Wolff. "This recommendation was made because of the difficulty in using only clinical signs to confirm correct endotracheal tube placement," she explains.
• Observe for rise and fall of the child’s chest. The smaller the child, the more likely that the chest and abdomen might rise and fall with ventilation, says Holleran. "If the child has been ventilated with a bag-valve mask before intubation, there may be air in his or her stomach," she notes. All intubated children need a gastric tube inserted to decompress the stomach and protect them from aspiration, Holleran adds.
• Use Pedi-Cap. This end-tidal CO2 detector, manufactured by St. Louis-based Mallinckrodt, contains a chemically treated indicator that reacts with CO2 and changes color when the tube is in the trachea, says Holleran. (See contact information for Mallinckrodt at end of article.) "When intubated, the strip should go from purple to yellow with about five breaths," says Holleran. "If there is poor perfusion or the strip has been exposed to fluids, it may not function."
• Attach end-tidal monitors to cardiac monitors. These can provide both a quantitative readout as well as a waveform to monitor the CO2, says Holleran. For example, Protocol monitors have a module that will give a numerical CO2 reading and a waveform that indicates CO2 output, says Holleran. This can be correlated to ventilation and perfusion, she notes. (Protocol monitors are manufactured by Protocol Systems. See contact information at end of article.)
• Assess changes in pulse and heart rate. Depending on the age of the child, the heart rate may range from 80 to 120 or higher, says Holleran. Hypoxia in children is manifested by bradycardia, she says. "A sudden change in heart rate may indicate tube dislodgement," she notes.
For more information about endotracheal tube placement, contact:
• Reneé Holleran, RN, PhD, University of Cincinnati Medical Center, P.O. Box 670736, Cincinnati, OH 45267. Telephone: (513) 584-7522. Fax: (513) 584-4533. E-mail: hollerre@Healthall.com.
• Michele Wolff, RN, MSN, CCRN, Saddleback College, 28000 Marguerite Parkway, Mission Viejo, CA 92692. Telephone: (949) 582-4222. Fax: (714) 536-6269. E-mail: firstname.lastname@example.org.
For more information about Protocol monitors, contact Welch Allyn Protocol, 8500 S.W. Creekside Place, Beaverton, OR 97008. Telephone: (800) 289-2500 or (503) 526-8500. Fax: (503) 526-4200. E-mail: email@example.com. Web: www.protocol.com.
For more information about PediCap carbon dioxide detectors for verification of endotracheal tube placement, contact Mallinckrodt, 675 McDonnell Boulevard, St. Louis, MO 63134. Telephone: (800) 635-5267 or (314) 654-7004. Fax: (888) 222-9799. E-mail: firstname.lastname@example.org. Web: www.mallinckrodt.com/respiratory.