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Logo of archdischfnArchives of Disease in Childhood - Fetal & NeonatalVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
Arch Dis Child Fetal Neonatal Ed. 2007 May; 92(3): F233–F234.
PMCID: PMC2675342

Malposition of endotracheal tube: association with pneumothorax in ventilated neonates

The incidence of pneumothorax in neonates has decreased with of use of antenatal steroids in women at risk of preterm delivery, surfactant treatment and new modes of respiratory support.1 We reviewed the records of ventilated neonates with a diagnosis of pneumothorax, born between September 1997 and September 2003, to identify its risk factors. A group of concurrently born, ventilated neonates of same gestation and birth weight who did not have pneumothorax served as the control group. The characteristics studied were positive end expiratory, peak and mean airway pressures, oxygen requirement, blood gases and surfactant doses. Diagnosis of pneumothorax, its laterality and the position of the endotracheal tube (ETT) were determined by reviewing the x rays. ETT displacement or malposition was defined as movement of the tube either to or beyond the carina after its initial correct placement had been confirmed radiographically.

The clinical characteristics and initial respiratory support of both groups were comparable. Of the ventilated neonates who developed pneumothorax, 76% (22/29) were preterm and 52% (15/29) were born at less than 28 weeks' gestation. The mean age of development of pneumothorax was 24 hours and 93% (27/29) occurred within 96 hours after birth. The ETT was displaced in 16/25 (64%) babies with pneumothorax compared with only 5/27 (18.5%) in the control group (p = 0.0008). Pneumothorax occurred mostly (72.5%) on the right side; in 67% of cases this was associated with the ETT in the right main bronchus. In babies with left‐sided pneumothorax, the ETT was either in an appropriate position or at the carina. No baby in the comparison group had ETT displacement beyond the carina.

Development of pneumothorax in ventilated neonates is associated with underlying lung disease and high peak inspiratory pressure and inspiratory time. Despite modern practice of less aggressive ventilation, pneumothorax occurs in ventilated neonates,2 suggesting that other factors contribute to its development. We found ETT displacement was significantly higher in the group with pneumothorax. An ETT is generally secured at the lip or the angle of the mouth by an adhesive tape. However, because of the loose musculature of the preterm neonate there may be inward and outward movement of the tube. Head movements, suctioning, secretions and patient handling can cause displacement of the tube. We believe that by properly stabilising an ETT with holders or other measures, and by paying close attention to other factors that lead to ETT displacement in preterm neonates, the incidence of pneumothorax in this population may be further reduced.


Competing interests: none.


1. Henderson‐Smart D J, Bhutta T, Cools F. et al Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2003. (4)CD000104 [PubMed]
2. Harbor J D, Badger G J, Carpenter J H, Members of the Vermont Oxford Network et al ; Trends in mortality and morbidity for very low birth weight infants, 1991–1999. Pediatrics 2002. 110143–151.151 [PubMed]

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