393 - Standard Nasal-Tragus Length versus Alternate Insertional Length Formula for Optimal Placement of Endotracheal Tube in Neonates-A Randomized Controlled Trial (SNAIL Trial)

Publication Number: 393.6910

Sachin Dangi, Sir Ganga Ram hospital, New Delhi, Rohtak, Haryana, India; Pankaj Garg, Sir Ganga Ram Hospital, Delhi, Delhi, India; Anup Thakur, Sir Ganga Ram Hospital, New Delhi, New Delhi, Delhi, India; Neelam Kler, Sir GangaRam Hospital India, NEW DELHI, Delhi, India; Satish Saluja, Sir Ganga Ram Hospital, NEW DELHI, Delhi, India; Manoj Modi, Sir Ganga Ram Hospital, New Delhi, Delhi, India; Arun Soni, Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, Delhi, Delhi, India

Background: Current guidelines recommend to use standard formula based on nasal tragus length i.e., NTL+1 cm to estimate insertional length (IL) during endotracheal intubation. However, recent studies from Asia indicate that this formula may lead to malposition of endotrachal tube (ETT). Based on our previous study, we derived an alternate nasal tragus formula for the calculation of IL. We compared alternate NTL formula with standard NTL formula for optimal placement of endotracheal tube.

Objective: To compare the alternate nasal-tragus length formula with standard nasal tragus length formula for optimal placement of ETT.

Design/Methods: This randomized controlled trial was conducted in a level IIIB NICU in India from June 2022 to December 2023. Neonates who required endotracheal intubation were randomized to either standard NTL group or alternate NTL group. In standard NTL group, the IL of ETT was calculated as NTL+ 1cm and in the alternate NTL group, IL was calculated as IL = NTL +0.5 cm for a measured NTL upto 5.5 cm and IL=NTL for a measured NTL more than 5.5 cm.

Results: A total of 158 neonates were randomized. After post randomization exclusion, 74 neonates in alternate NTL group and 76 in standard NTL group were analyzed. The baseline maternal and neonatal characteristics were similar in two groups. The mean (SD) gestational age in alternate NTL and standard NTL group was 32.6 (4) weeks and 33.8 (3.9) weeks respectively. The mean birth weight (SD) was 1817 (811) g and 1896 (718) g in alternate NTL and standard NTL group respectively. Small for gestational age neonates were similar in both groups. (Table-1)
Higher rate of optimal position of endotracheal tube was seen in alternate NTL group compared to standard NTL group [48 (65%) and 30 (39%), respectively] (p=0.002). Low placement of endotracheal tube was more frequent in standard NTL group compared to alternate NTL group [41 (54%) and 14 (19%), respectively] (p < 0.001). There was trend toward high placement of endotracheal tube in alternate NTL group but the difference was not statistically significant [12 (16%) and 5 (7%), respectively (p = 0.06). Other secondary outcomes including reintubation within 1 hour, need for mechanical ventilation for >72 hours, pneumothorax or other air leak syndromes, lung atelectasis and mortality were similar in both groups. (Table-2)

Conclusion(s): Use of alternate nasal tragus length formula in neonates requiring endotracheal intubation leads to a higher rate of optimal placement of endotracheal tube compared to standard NTL formula.

Table 1- Baseline Maternal and Neonatal Characteristics


Table 2- Primary and Secondary Outcomes