Article, Intubation

Chest x-ray or fiber optic bronchoscopy for confirmation of endotracheal tube depth


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American Journal of Emergency Medicine

journal homepage: www. locate/ajem

Reconfirmation of endotracheal tube depth after clinical method?,??

To the Editor,

I have read with great interest the article of Hossein-Nejad et al [1]. Although I think the authors’ idea to reconfirm the endotracheal tube depth after clinical methods is very good, I do have 2 questions about this article.

The first question is about the statistical data, which demonstrated that women had a deeper intubation than men in both total and appropriate depths of the endotracheal tube, respectively. I wonder if these statistical data are actually true or not. To the best of my knowledge, men generally have a higher height than do women; thus, men should need an approximately 2-cm deeper intubation than women do. As stated in this article, female patients were more likely to have an inappropriate intubation [2]. This is due to the shorter trachea in their anatomy. What attracted my attention to ask was why did this contradiction happen? Was it influenced by the exclusion criteria or by the position of the head during the Chest x-ray examination? Of course, this contradiction could also be a reason for us to reconfirm the endotracheal tube depth after clinical methods.

The second question is about the way to reconfirm the endotracheal tube depth after clinical methods. Although reconfir- mation of endotracheal tube depth with CXR is necessary, CXR has its own shortcomings too. For instance, it is almost impossible to use chest radiography in a situation outside the hospital, and it is also difficult to use it frequently in the intensive care unit because of the concerns for inherent radiation exposure [3]. As an anesthesiologist, I use fibrotic bronchoscope (FOB) instead. Because FOB is small and portable, it can be conveniently used in operating room, emergency department, and intensive care unit, and even at the situation outside hospital. Some investigators argued that the inexperienced operators of FOB may have difficulty in using it. This problem may also often happen in intubation. Actually, we have found that it is easy to measure the distance between the tube tip and the carina in intubated patients.

Jing Wang, MD Yunxia Zuo, PhD

Department of Anaesthesiology, West China Hospital,

Chengdu 610041, China E-mail addresses: [email protected], [email protected]

? Funding: This work was funded by the Department of Anaesthesiology, West China Hospital.

?? The work is attributed to West China Hospital. It is supported by the Department

of Anaesthesiology, West China Hospital. It has not been presented at any meeting.


  1. Hossein-Nejad H, Payandemehr P, Bashiri SA, Nedai HH. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31: 1181-2.
  2. Schwartz DE, Lieberman JA, Cohen NH. Women are at greater risk than men for malpositioning of the endotracheal tube after emergent intubation. Crit Care Med 1994;22:1127-31.
  3. Reicher J, Reicher D, Reicher M. Use of radio frequency identification (RFID) tags in bedside monitoring of endotracheal tube position. J Clin Monit Comput 2007;21: 155-8.

    Chest x-ray or fiber optic bronchoscopy for confirmation of endotracheal tube depth

    To the Editor,

    I would like to offer my gratitude to Dr Yunxia’s thoughtful attention to our work.

    In response to his first question, it should be mentioned that all our data and analyses have been rechecked frequently. Therefore, I think statistical results are correct and accurate. That we did not find any statistical difference between sexes can be due to several reasons. First, the acceptable distance from carina can be 2 to 7 cm; thus, deeper insertion of endotracheal tube , 1 to 2 cm in this range, would be interpreted as correct, and as a result of this wide range of acceptable distance, small differences between sexes cannot be detected statistically and will not affect the results. Second, some studies have shown that most depth-related misplacements happen in women, and it is more probable to place the ETT in deeper positions in women than in men [1,2]. Third, as it is mentioned in our study, our sample size were mainly old people [3]. To the best of our knowledge, anatomical difference in this group is not investigated specifically and is not clear.

    With respect to the second question, fiber optic bronchoscopy (FOB) is one of the best methods for both placement and confirmation of ETT in some circumstances, but FOB usage as a routine method for confirmation of all intubations (that is aimed in our survey) may not be feasible in a crowded emergency department. However, in some difficult cases, it can effectively contribute to ETT placement and adjust the depth. Furthermore, chest x-ray has little radiation (b 5 MRAD), is not as costly as FOB and does not require as much skill to be obtained.

    Hooman Hossein-Nejad, MD Department of Emergency Medicine, Imam Hospital Tehran University of Medical Sciences

    Tehran, Iran E-mail address: [email protected]

    0735-6757/(C) 2014


    Everon SH, Weisenberg M, Haroe E, et al. Proper insertion depth of endotracheal tubes in adults bytopographic landmarks measurements. J Clin Anesth 2007;19:15-9.

  4. Rigini N, Boaz M, Ezri T, et al. Prompt correction of endotracheal tube positioning after intubation prevents further inappropriate positions. J Clin Anesth 2011;23:367-71.
  5. Hossein-nejad H, Payandemehr P, Bashiri SA, et al. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31(8):1181-2.

    Coexisting subarachnoid haemorrhage and pneumocephalus is really rare??

    To the Editor,

    We read with great interest the article “Subarachnoid hemorrhage and pneumocephalus due to Epidural anesthesia; a rare case” written by Guzel et al [1]. The authors shared a case of Severe headache and irritability due to provided epidural anesthesia during vaginal delivery and stated in their discussion that there was no report in the literature about association of pneumocephaly and subarachnoid bleeding.

    Subarachnoid hemorrhage is an entity associated with headache, which may present after lumbar puncture [2,3]. Pneumocephaly is a well-described complication of unintentional dural puncture. Both conditions may be encountered especially after trauma and accompany one another. There are, in fact, existing cases related to posttraumatic pneumocephalus and subarachnoid hemorrhage in the literature that have been reported to be seen together [4,5].

    The authors need to clarify several discrepancies in their case report as well. The patient is noted to have been discharged to home on the day 20 after presentation in the abstract, but then state that the patient had stayed in the intensive care unit for 28 days due to pulmonary problems and was then discharged to home in the penultimate sentence of a case-report section.

    Salim Kemal Tuncer, MD Yusuf Emrah Eyi, MD Umit Kaldirim, MD Ibrahim Arziman, MD

    Department of Emergency Medicine Gulhane Military Medical Academy School of Medicine

    Ankara, Turkey E-mail address: [email protected]

    Ali Osman Yildirim, MD Department of Emergency Medicine GATA Haydarpasa Training Hospital

    Istanbul, Turkey

    Emre Zorlu, MD

    Department of neurosurgery GATA Haydarpasa Training Hospital

    Istanbul, Turkey


    Guzel M, Salt O, Erenler AK, Baydin A, Demir MT, Yalcin A, Doganay Z. Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia: a rare case. Am J Emerg Med. Available online 28 January 2014.

  6. Pancu D, Davenport M, Roth K, Heller M. EPs do not accept the strategy of “lumbar puncture first” in subarachnoid hemorrhage. Am J Emerg Med 2004;22(2):115-7.
  7. Mark DG, Pines JM. The detection of nontraumatic subarachnoid hemorrhage: still a diagnostic challenge. Am J Emerg Med 2006;24(7):859-63.
  8. Zhang YX, Liu LX, Qiu XZ. A case report of diffuse pneumocephalus induced by sneezing after brain trauma. Chin J Traumatol 2013;16(4):249-50.
  9. Koizumi H, Miyasaka Y, Tanaka C, Fujii K. A case of open head injury caused by electric saw. No Shinkei Geka 2011;39(6):611-4.

    Acute abdominal pain and dengue fever

    To the Editor,

    Sir, the report on acute abdominal pain and dengue fever is quite interesting [1]. In fact, the atypical presentation of dengue can be seen and this can be sometimes difficult to diagnose [2]. Focusing on abdominal pain, it is not an uncommon presentation. According to a recent report from Brazil [3], Pires et al. noted that “fever, abdominal pain and vomiting” were the three main clinical presentations of dengue fever. Duran et al. reported that abdominal pain was very common in severe dengue case [4]. Hence, the case of dengue presenting with abdominal pain is not an unusual case at all. With expanding endemic area of dengue, dengue should be a differential diagnosis in an emergency case presenting with abdominal pain.

    Viroj Wiwanitkit Surin Rajabhat University Surin Province, Thailand

    E-mail address: [email protected]


    Waseem T, Latif H, Shabbir B. An unusual cause of acute abdominal pain in dengue fever. Am J Emerg Med 2014 pii: S0735-6757(14)00017-5. doi: 10.1016/j. ajem.2014.01.011. [Epub ahead of print].

  10. Wiwanitkit V. Dengue fever: diagnosis and treatment. Expert Rev Anti Infect Ther 2010;8(7):841-5.
  11. Pires RD, Neto L, Sa SL, Pinho SC, Pucci FH, Teofilo CR, et al. Dengue infection in children and adolescents: Clinical profile in a reference hospital in northeast Brazil. Rev Soc Bras Med Trop 2013;46(6):765-8.
  12. Duran A, Ochoa E, Alcocer S, Gomez M, Millano M, Martinez O, et al. Frequency of gastrointestinal signs and symptoms of dengue. Analysis of a cohort of 1484 patients. Invest Clin 2013 Sep;54(3):299-310.

    ED visits and spending by unauthorized immigrants compared with legal immigrants

    and US natives?,??

    To the Editor,

    In light of the ongoing debate about immigration reform, a recent study found that contributions by immigrants to the Medicare Trust Fund outweigh their expenditures [1]. Another 2013 study found that health expenditures are lower for unauthorized immigrants and legal residents than US natives and naturalized citizens [2]. However, evidence for the emergency department (ED) setting is limited, where much of the debate on health service utilization of unauthorized immigrants is concentrated. The most recent study of ED utilization found that noncitizen immigrants used significantly less ED services compared with citizens [3]. However, that study did not have an estimate for unauthorized immigrants. Given the continuing debate about the impact of immigrants on the health system, especially the potential impact of unauthorized immigrants, we compared differences in ED utilization and medical expenditures by nativity and legal status. We used the 2002 to 2011 Medical Expenditure Panel Survey (MEPS)

    to examine ED utilization and expenditures for US natives, naturalized

    ? We have no support in financial or other relationships that might lead to a conflict of interest.

    ? Grant or other financial support: None.

    ?? Conflicts of interest: None.

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