Assessment of techniques to ascertain correct placement of a breathing tube in neonates

When a newborn baby requires a tube to be inserted into the windpipe to help him/her breathe, the clinical team can take a radiograph (X-ray) to confirm that the tube is correctly positioned. Because this is often delayed, however, newer techniques aimed at rapidly confirming the correct placement of the breathing tube within the windpipe have been developed. The rapid confirmation of correct tube placement is important because a wrongly placed tube can result in serious adverse outcomes, including death, low levels of oxygen in the blood, an abnormal collection of air or gas between the lung and the chest wall, which can interfere with breathing, or the collapse of the lung. New techniques for the rapid determination of tube placement include the use of clinical signs, the measurement of air going in and out of the lung (using a respiratory function monitor), measuring the amount of exhaled carbon dioxide (CO2) and using ultrasound to image the tube within the windpipe.

The aim of this study was to compare chest X-ray with any of these new techniques for determining the correct placement of the breathing tube in newborn infants, in either the delivery room or the intensive care unit, and to determine subsequent mortality and morbidity in newborn infants who have been intubated. However, we were unable to identify any studies that met our inclusion criteria.

Authors' conclusions: 

There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.

Read the full abstract...

The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.

ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement.


To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions.

Selection criteria: 

We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit.

Data collection and analysis: 

Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria.

Main results: 

We did not identify any studies meeting the criteria for inclusion in this review.