Endotracheal Tube Position in Neonates Sir.\p=m-\Therecent study of Rotschild et al1 provides useful data for predicting the length of endotracheal tube required in neonates from external measurements. In common with other studies in both adults2 and neonates,3-5 Rotschild et al found that correct endotracheal tube positioning is dependent on the state of flexion or extension of the neck. Whether endotracheal tube position is confirmed with
radiography, palpation,6 ultrasonography,7 bronchoscopy,8 transtracheal
illumination,9 or magnetic detection,10
the position of the head and neck relative to the trunk is crucial to the interpretation of these estimations. Rotschild et al conclude their article by recommending that the infant's head be held in the "neutral position" when localizing of the tip of the endotracheal tube is attempted. The problem is ensuring that this "neutral position" is maintained from one examination to the next. We have addressed this question in our unit with a device designed to help maintain a constant neutral po-
sition of the head and neck during roentgenographic examination. It con¬ sists of a rigid plastic form with a
cutout to accommodate the infant's neck, and right-angle pieces at either end to ensure that the device stands
upright when placed firmly on the roentgenographic plate (Figure). Three
different sizes are available to accom¬ modate different-sized infants. When correctly positioned, the infant's chin is opposed to one side of the plastic sheet, and the shoulders to the other side, which results in very little flex¬ ibility of the head and neck relative to the trunk. The roentgenogram is then taken. We have found this device to be simple to use and easy to make in house, and we believe it has assisted us in our interpretation of endotra¬ cheal tube position. PHILIP C. ETCHES, MB NEIL N. FINER, MD Royal Alexandra Hospital 10240 Kingsway Edmonton, Alberta, Canada T5H 3V9 1. Rotschild
A, Chitayat D, Puterman ML,
Baldwin V. Optimal positiontubes for ventilation of preterm infants. AJDC. 1991;145:1007-1012. 2. Conrardy PA, Goodman LR, Lainge F, Singer MM. Alteration of endotracheal tube posi-
Phang MS, Ling E,
ing of endotracheal
tion: flexion and extension of the neck. Crit Care Med. 1976;4:8-12. 3. Kuhns LR, Poznanski AK. Endotracheal tube position in the infant. J Pediatr. 1971;78: 991-996. 4. Todres ID, deBros F, Kramer SS, Moylan FMB, Shannon DC. Endotracheal tube displacement in the newborn infant. J Pediatr. 1976;89:126-127. 5. Roopchand R, Roopnarinesingh S, Ramsewak S. Instability of the tracheal tube in neo-
study.
Anaesthesia. 1989;
palpation: a new technique.
Pediatrics. 1975;56:
nates:
a
post
mortem
44:107-109. 6. Bednarek FJ, Kuhns LR. Endotracheal tube placement in infants determined by suprasternal 224-229. 7. Slovis neonates:
TL, Poland RL. Endotracheal tubes in
sonographic positioning. Radiology.
1986;160:262-263. 8. Vigneswaran R, Whitfield JM. The use of a new ultra-thin fiberoptic bronchoscope to determine endotracheal tube position in the sick newborn infant. Chest. 1981;80:174-177. 9. Stewart RD, LaRosee A, Kaplan RM, Ilkhanipour K. Correct positioning of an endotracheal tube using a flexible lighted stylet. Crit Care Med. 1990;18:97-99. 10. Blayney M, Costello S, Perlman M, Lui K, Frank J. A new system for location of endotracheal tube in preterm and term neonates. Pediatrics. 1991;87:44-47.
Syringomas in Down Syndrome Sir.\p=m-\Inthe
September
1991 issue of
AJDC1 Feingold described patients
with Down syndrome with facial lesions. He found that 15 (46.9%) of the 32 patients with Down syndrome had syringomas. Although I do not disagree that patients with Down syndrome have an increased incidence of syringomas, none of these patients underwent a biopsy of these lesions for verification of the diagnosis. Multiple lesions in the periorbital area could not only be syringomas but trichoepitheliomas, xanthomas, and other adnexal tumors. For this reason I disagree with Dr Feingold's final statement, ". . not subject the patient to an unnecessary evaluation." SUSAN B. MALLORY, MD .
Dermatology
St Louis Children's Hospital 400 S Kingshighway Blvd St Louis, MO 63110
1.
Plastic form in
position.
Feingold
M.
Syringomas
in Down syn-
drome. AJDC. 1991;145:966-967.
Downloaded From: http://archpedi.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 05/29/2015
radiography, palpation,6 ultrasonography,7 bronchoscopy,8 transtracheal
illumination,9 or magnetic detection,10
the position of the head and neck relative to the trunk is crucial to the interpretation of these estimations. Rotschild et al conclude their article by recommending that the infant's head be held in the "neutral position" when localizing of the tip of the endotracheal tube is attempted. The problem is ensuring that this "neutral position" is maintained from one examination to the next. We have addressed this question in our unit with a device designed to help maintain a constant neutral po-
sition of the head and neck during roentgenographic examination. It con¬ sists of a rigid plastic form with a
cutout to accommodate the infant's neck, and right-angle pieces at either end to ensure that the device stands
upright when placed firmly on the roentgenographic plate (Figure). Three
different sizes are available to accom¬ modate different-sized infants. When correctly positioned, the infant's chin is opposed to one side of the plastic sheet, and the shoulders to the other side, which results in very little flex¬ ibility of the head and neck relative to the trunk. The roentgenogram is then taken. We have found this device to be simple to use and easy to make in house, and we believe it has assisted us in our interpretation of endotra¬ cheal tube position. PHILIP C. ETCHES, MB NEIL N. FINER, MD Royal Alexandra Hospital 10240 Kingsway Edmonton, Alberta, Canada T5H 3V9 1. Rotschild
A, Chitayat D, Puterman ML,
Baldwin V. Optimal positiontubes for ventilation of preterm infants. AJDC. 1991;145:1007-1012. 2. Conrardy PA, Goodman LR, Lainge F, Singer MM. Alteration of endotracheal tube posi-
Phang MS, Ling E,
ing of endotracheal
tion: flexion and extension of the neck. Crit Care Med. 1976;4:8-12. 3. Kuhns LR, Poznanski AK. Endotracheal tube position in the infant. J Pediatr. 1971;78: 991-996. 4. Todres ID, deBros F, Kramer SS, Moylan FMB, Shannon DC. Endotracheal tube displacement in the newborn infant. J Pediatr. 1976;89:126-127. 5. Roopchand R, Roopnarinesingh S, Ramsewak S. Instability of the tracheal tube in neo-
study.
Anaesthesia. 1989;
palpation: a new technique.
Pediatrics. 1975;56:
nates:
a
post
mortem
44:107-109. 6. Bednarek FJ, Kuhns LR. Endotracheal tube placement in infants determined by suprasternal 224-229. 7. Slovis neonates:
TL, Poland RL. Endotracheal tubes in
sonographic positioning. Radiology.
1986;160:262-263. 8. Vigneswaran R, Whitfield JM. The use of a new ultra-thin fiberoptic bronchoscope to determine endotracheal tube position in the sick newborn infant. Chest. 1981;80:174-177. 9. Stewart RD, LaRosee A, Kaplan RM, Ilkhanipour K. Correct positioning of an endotracheal tube using a flexible lighted stylet. Crit Care Med. 1990;18:97-99. 10. Blayney M, Costello S, Perlman M, Lui K, Frank J. A new system for location of endotracheal tube in preterm and term neonates. Pediatrics. 1991;87:44-47.
Syringomas in Down Syndrome Sir.\p=m-\Inthe
September
1991 issue of
AJDC1 Feingold described patients
with Down syndrome with facial lesions. He found that 15 (46.9%) of the 32 patients with Down syndrome had syringomas. Although I do not disagree that patients with Down syndrome have an increased incidence of syringomas, none of these patients underwent a biopsy of these lesions for verification of the diagnosis. Multiple lesions in the periorbital area could not only be syringomas but trichoepitheliomas, xanthomas, and other adnexal tumors. For this reason I disagree with Dr Feingold's final statement, ". . not subject the patient to an unnecessary evaluation." SUSAN B. MALLORY, MD .
Dermatology
St Louis Children's Hospital 400 S Kingshighway Blvd St Louis, MO 63110
1.
Plastic form in
position.
Feingold
M.
Syringomas
in Down syn-
drome. AJDC. 1991;145:966-967.
Downloaded From: http://archpedi.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 05/29/2015
