Neonatal Endotracheal Tube Position On Chest Radiographs

Correct endotracheal tube placement is a time-critical concern in neonatal care. A tube that sits too high may slip out of the trachea, while one advanced too far can enter a main bronchus and impair ventilation to the opposite lung. In a small newborn, a movement of only a few millimetres can materially change the position of the tip.

Neonatal Endotracheal Tube Position: Radiographic Verification is therefore a practical skill involving more than locating a white line on a film. The clinician must assess the tube tip, airway anatomy, head and neck position, lung expansion, and the clinical response to ventilation. Radiography supports that assessment, but it does not replace continuous bedside observation.

The subject also sits within the wider history of perinatal and neonatal research. The FAOPS 2020 site was created for a Tokyo congress involving the Federation of Asian and Oceania Perinatal Societies and PREBIC AA 2020, with a scientific focus that included neonatal medicine. The meeting was cancelled in April 2020 because of the pandemic and international travel restrictions, yet the clinical questions remain highly relevant to neonatal teams.

In Australia, practice may involve a large tertiary neonatal intensive care unit in Melbourne, Sydney or Brisbane, a regional hospital working with a retrieval service, or a remote setting supported by telehealth and aeromedical transport. Portable radiography, electronic image sharing and local neonatal protocols help teams make decisions quickly, but image quality and access to paediatric radiology can vary considerably.

Why Tube Depth Matters In Newborns

A newborn’s trachea is short, so the safety margin between an appropriately positioned tube and a mainstem bronchus is narrow. Excessive insertion commonly directs the tube into the right main bronchus because of the airway’s anatomy. This can produce unilateral ventilation, reduced aeration of the left lung and progressive collapse. A tube positioned too shallowly may sit near the vocal cords or become displaced when the infant’s head moves.

The consequences may appear as changing oxygen requirements, unequal chest movement, reduced air entry, poor carbon dioxide clearance or unexpected difficulty providing effective ventilation. These signs should prompt an immediate bedside review rather than waiting for a routine film. Tube depth at the lip should be documented, along with the tube size, insertion method and any subsequent adjustment.

Head and neck position is especially important. Neck flexion tends to advance the tube relative to the carina, whereas extension can withdraw it. A radiograph taken with the infant’s head turned or flexed may therefore show a position that changes when the baby is repositioned. The image should be interpreted in the context of how the infant was positioned at the time.

Reading The Neonatal Chest Film

A neonatal chest radiograph is usually an AP portable image obtained with the infant supine. Start by checking technical factors: rotation, exposure, degree of inspiration, field of view and whether the head and neck are neutral. Rotation can make the mediastinum appear asymmetric and can complicate comparison of lung volumes. Poor inspiration may mimic diffuse lung disease or obscure the assessment of tube depth.

Trace the endotracheal tube from the connector through the neck and thorax. The radiopaque marker or line can help, but it should not be mistaken for the actual distal end of the tube. Identify the tip in relation to the carina, thoracic inlet, clavicles and vertebral bodies. Many neonatal protocols aim for the tip in the mid-trachea, commonly around the level of the upper to mid-thoracic vertebrae and clearly above the carina. The exact acceptable range depends on the infant’s size, tube type, local policy and the quality of the image.

The carina may be difficult to see in a premature infant, particularly when the lungs are poorly expanded or there is overlapping cardiac and mediastinal shadowing. A careful reader should assess the whole film rather than relying on a single landmark. Lung asymmetry, lobar atelectasis, mediastinal shift and gastric distension may provide supporting evidence of tube position or another complication.

Choosing The Right Confirmation Method

Radiography is valuable after intubation when the clinical situation permits, especially after a difficult procedure, an unexpected deterioration, a transfer or a significant tube adjustment. It can reveal depth, lung expansion and associated findings such as pneumothorax. However, it is not an instantaneous test and should not delay effective ventilation or urgent correction of an obviously displaced tube.

Exhaled carbon dioxide detection and clinical signs are particularly important during initial resuscitation. In a critically unstable newborn, the tube should be treated as potentially displaced if the heart rate, chest movement or oxygenation does not improve as expected. A later chest film can then verify depth and identify complications once immediate ventilation has been stabilised.

Common Radiographic Malpositions

A high tube tip may be located in the cervical trachea or close to the vocal cords. It can be vulnerable to accidental extubation when the infant’s head is extended, when tapes loosen or during transfer between an incubator and a transport cot. On the radiograph, the tube may appear well within the airway but still be too close to the thoracic inlet for the clinical circumstances. The appropriate response is guided by the film, measured depth and the treating team’s protocol.

A low tube tip may pass through or approach the carina, most often entering the right main bronchus. Look for reduced left-sided aeration, asymmetric lung volumes or focal atelectasis. However, lung changes can lag behind the tube movement, so a normal-looking film does not make a tube that is visibly too deep safe. Small corrections should be followed by reassessment, and a repeat image may be required.

Other findings deserve attention at the same time. A radiograph may show pneumothorax, pulmonary interstitial emphysema, atelectasis, overdistension or an incorrectly positioned nasogastric tube. The tube itself can be kinked, compressed or obscured by equipment. In a busy Australian NICU, where a portable film may be acquired during a retrieval preparation or after transfer from theatre, checking the entire image prevents the depth question from eclipsing a second urgent problem.

Making The Result Clinically Useful

Documentation should state the tube size, insertion depth at the lip, date and time, patient position, radiographic assessment and any action taken. Rather than recording only “ETT satisfactory,” a useful entry describes the tip in relation to the carina and notes whether lung expansion is symmetrical. This creates a clear baseline for later films and helps the next clinician recognise migration.

The tube can move with changes in head position, growth, handling and fixation. A newborn transferred from a special care nursery in regional Victoria to a tertiary centre may have several opportunities for displacement during preparation and transport. Likewise, an infant in a metropolitan unit may need a fresh assessment after re-taping, procedures or a change from invasive ventilation to another mode.

Radiographs should be interpreted with the clinical picture and local neonatal guidance. If the film and the bedside signs disagree, escalate promptly to the responsible neonatologist or retrieval consultant. In remote Australia, image review through a secure PACS or telehealth pathway can be especially useful, while the local team continues ventilation and monitoring rather than waiting passively for a formal report.

A consistent approach is simple: confirm the airway clinically, inspect the image systematically, locate the tip relative to the carina, assess both lungs, correct an unsafe position and document the result. This method supports safe care across major hospitals, regional services and the long distances that characterise Australian neonatal transport.

Use this framework alongside your unit’s neonatal resuscitation policy, radiology standards and senior clinical advice. Teams can strengthen practice by reviewing anonymised films in teaching sessions, comparing radiographic findings with tube depth and clinical events, and ensuring that every staff member knows the escalation pathway. Accurate verification begins with a careful image, but safe airway management continues at the bedside.