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J Emerg Med. 2016 Jul;51(1):9-18. doi: 10.1016/j.jemermed.2016.04.007. Epub 2016 May 25.

Factors Associated with Misplaced Endotracheal Tubes During Intubation in Pediatric Patients.

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Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.
Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.



Correct positioning of the endotracheal tube (ETT) during emergent pediatric intubations can be challenging, and incorrect placement may be associated with higher rates of complications.


The aims of this study are to: 1) assess the prevalence of clinically undetected misplaced ETTs after intubation in the pediatric emergency department; 2) identify predictors of ETT misplacement; and 3) evaluate for any association between intubation-related complications and ETT position.


In this retrospective cross-sectional study, the primary outcome was rate of unrecognized low or high ETTs detected on confirmatory chest radiographs. The secondary outcome was frequency of complications (i.e., hypoxemia, difficult ventilation, atelectasis, pneumothorax, pneumomediastinum, and aspiration) associated with misplaced ETTs. Multivariable analyses were used to evaluate the associations between patient and procedural characteristics and misplaced ETTs and between ETT position and complications.


Seventy-seven of 201 (38.3%) intubations performed in the emergency department resulted in clinically unrecognized misplaced ETTs. Of the misplaced tubes, 45 of 77 (58%) were identified as low and 32 (42%) were high. In multivariable analyses, female sex and decreasing age were associated with increased risk of low tube placement (odds ratio for female sex, 2.4 [95% confidence interval, 1.1-5.1]; odds ratio of decreasing age, 1.16 [95% confidence interval, 1.0-1.3]). Low tube misplacement was associated with an increased risk of intubation-related complications compared to both correct and high tube placement (p < 0.05, Chi-square).


Clinically unrecognized ETT misplacement occurs frequently in the pediatric emergency department, with low placement being most common, particularly in girls and younger children. Measures to improve clinical or radiographic recognition of incorrect tube position should be considered.


airway; endotracheal tube; intubation; pediatric

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