INTRODUCTION:

Endotracheal tube (ETT) insertion is the primary method of definitive airway protection and control in critically ill patients. Detection of ETT malposition in a timely fashion is crucial in both elective and emergent intubation.

The goals of tracheal intubation are to place the tube in the trachea and to position the tube at an appropriate depth inside the trachea.¹

During ICU rounds, ET tube position is systematically assessed for placement, depth, and security. It keeps the tube in the right tracheal position and provides airway protection and ventilation.²

Endotracheal tubes that are positioned correctly may move due to patient or equipment movement. It is ideal to use continuous waveform capnography to continuously assess proper endotracheal tube placement. Every patient should have their endotracheal tube position confirmed right away if their clinical condition worsens or if there is ever any doubt as to where the tube should be placed.³

Need For ET Tube Position Confirmation:

· To ensure patient safety and airway patency.⁴

· To avoid unintended extubation or malposition (right main bronchus, esophageal).

· For proper oxygenation and ventilation.⁵

· To detect tube migration from patient movement, suctioning, coughing, or nursing.

· To prevent hypoxia, aspiration, and ventilator-associated pneumonia.

Methods of Et Tube Placement Confirmation:

Fig.1 Shows the Methods of Endotracheal tube Placement Confirmation

A. External Inspection:

· Check tube marking at lip/teeth for cm mark (20-22 cm in adults). Compare with intubation day documentation. Any change implies migration.⁶

· Fixation/security check: Ensure all ties/tape are secure and not should not be loose or displaced.⁷

B. Chest and epigastric auscultation: bilateral equal breath sounds, no epigastrium gurgling.⁸

C. Direct laryngoscopy (DL): It enables direct visualization of the ET tube entering the trachea through the vocal cords. If there is suspicion of tube displacement, partial extubation, or cuff leak and other bedside methods are inconclusive.⁹

D. Aspiration of the tube: we can attach a syringe to the ET tube and aspirate. We should get air easily if the tube is in the trachea. If after aspiration, we obtain gastric contents (acidic fluid, bile, food particles), it suggests the ET tube may have been mistakenly placed in the esophagus/stomach.¹⁰

E. Pulse oximetry: VA stable spo₂ (≥ 94–96%) suggests the ET tube is likely in the trachea and ventilating effectively. A sudden drop in Spo₂ may indicate tube displacement, obstruction, kinking, or disconnection.¹¹

F. Chest X-Ray: ET tube tip should be 2–3 cm above the carina in neutral head position. As Head/neck movement can change tube depth.¹²

If the above-mentioned methods do not yield reliable results, some advanced techniques to confirm endotracheal tube placement include:¹³

Video laryngoscopy

Ultrasonography (POCUS-Point of care USG)

Fibreoptic Bronchoscopy

Fig.2 shows the advance methods to verify the ET tube placement

1. Video laryngoscopy: Direct visualization of the endotracheal tube entering the trachea is made possible by video laryngoscopy, which offers a clear, magnified view of the vocal cords. It lowers the risk of esophageal intubation, increases accuracy in challenging airways, and enables multiple team members to verify placement using a shared video screen. VL is a useful teaching tool and can help determine tube depth. It improves the safety and dependability of ET tube placement verification, but it cannot take the place of radiography or capnography.¹⁴

2. USG POCUS (Point of care USG): By examining bilateral lung sliding and visualizing the tube passage between vocal cords (transtracheal view), bedside ultrasound can quickly confirm ETT placement. Esophageal intubation is ruled out when there is no "double-tract sign." When capnography is unreliable, like during cardiac arrest, it is quick, non-invasive, and useful.¹⁵

3. Fiberoptic Bronchoscopy: Known as the gold standard for direct visualization, bronchoscopy enables precise tube depth, carina, and tracheal ring confirmation. When precise adjustment is needed or there is a suspicion of malposition or airway trauma, it is especially helpful. However, it can be difficult with unstable patients and calls for knowledge and equipment availability.¹⁶

ADVANTAGES:

· Early displacement detection prevents hypoxia and cardiorespiratory compromise.

· Lowers complications (barotrauma, aspiration, atelectasis).

· Continuous vigilance improves patient safety.

· ICU rounds are more collaborative when nurses, doctors, and respiratory therapists monitor tube position.¹⁷

· Supports documentation and demonstrates regular airway monitoring.

· Improves care quality and follows critical care protocols.¹⁸

CONS/ RESTRICTIONS:

· Limited subjective assessment through visual inspection or auscultation may overlook subtle malposition.¹⁹

· Busy ICU rounds take time.²⁰

· Handling or inspecting risks accidental movement.²¹

· External inspection may not confirm intratracheal depth, requiring radiographic confirmation.²²

· Overreliance on inspection without capnography or chest X-ray may be misleading.²³

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

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Received on 21.08.2025 Revised on 08.11.2025

Accepted on 13.01.2026 Published on 30.07.2026

Available online from August 05, 2026

Int. J. Nursing Education and Research. 2026;14(3):263-265.

DOI: 10.52711/2454-2660.2026.00054

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