Accuracy of pediatric advanced life support method for predicting the depth of endotracheal tube in Indonesian children

  • Andi Ade Wijaya Ramlan Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
  • Adhrie Sugiharto Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
  • Agus Mutakim Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
Keywords: endotracheal tube, pediatrics, resuscitation
Abstract viewed: 247 times
PDF downloaded: 110 times
HTML downloaded: 7 times
EPUB downloaded: 28 times


BACKGROUND The pediatric advanced life support (PALS) method can predict the depth of endotracheal tube (ETT) in pediatric patients easily, but it has limitations due to variations in the children’s characteristics, especially the racial consideration. This study compared the accuracy of ETT depth prediction based on the PALS methods in Indonesian children.

METHODS Patients aged 0–12 years, who underwent elective surgery with oral intubation, were recruited consecutively based on their ages: 0–24 months and 25 months–12 years for this cross-sectional study in Cipto Mangunkusumo Hospital, Jakarta, Indonesia from June to August 2014. Bland–Altman analysis was used to compare the two measurement methods: PALS method to predict the ETT depth accuracy and auscultation method to confirm the position of the ETT. Furthermore, correlation analysis was done to examine the relationship of age, weight, height, and ETT internal diameter with ETT depth.

RESULTS 50 patients were recruited in each group. Bland–Altman test of ETT depth in the 0–24 months age group showed a 1.18 cm mean difference from confirmation using the auscultation method (limits of agreement −0.71 to 3.08). The 25 months–12 years age group showed a 1.11 cm mean difference with limits of agreement were −0.95 to 3.17 from confirmation using the auscultation method. Age and weight had the strongest correlation value to ETT depth in the 25 months–12 years age group (R2 = 62.3%).

CONCLUSIONS The PALS method is inaccurate for predicting ETT depth in Indonesian children aged 0–12 years old compared with the auscultation method.


  1. Cote CJ. Pediatric anesthesia in Miller Anesthesia. 7th ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 2577−82.

  2. Motoyama EK, Gronert BJ, Fine GF. Induction of anesthesia and maintenance of the airway in infants and children. In: Motoyama E, Davis P. Smith's anesthesia for infants and children. 7th ed. USA: Elsevier Mosby; 2011. p. 319−53.

  3. Boensch M, Schick V, Spelten O, Hinkelbein J. [Estimation of the optimal tube length: systematic review article on published formulae for infants and children]. Anaesthesist. 2016;65(2):115−21. German.

  4. Gamble JJ, Mckay WP, Wang AF, Yip KA, O'Brien JM, Plewes CE. Three-finger tracheal palpation to guide endotracheal tube depth in children. Pediatr Anaesth. 2014;24(10):1050−5.

  5. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S876−908.

  6. Pak HJ, Hong BH, Lee WH. Assessment of airway length of Korean adults and children for otolaryngology and ophthalmic surgery using fiberoptic bronchoscope. Korean J Anesthesiol. 2010;59(4):249−55.

  7. Schmölzer GM, O'Reilly M, Davis PG, Cheung PY, Roehr CC. Confirmation of correct tracheal tube placement in newborn infants. Resuscitation. 2013;84(6):731−7.

  8. Batubara J, Alisjahbana A, JGMGerver-Jansen A, Alisjahbana B, Sadjimin T, Tasli Y, et al. Growth diagrams of Indonesian children: the nationwide survey of 2005. Paediatr Indones. 2006;46(5−6):118−26.

  9. Hunyady AI, Pieters B, Johnston TA, Jonmaker C. Front teeth-to-carina distance in children undergoing cardiac catheterization. Anesthesiology. 2008;108(6):1004−8.

  10. Blumenfeld J. Racial identification in the skull and teeth. Totem Univ Ont J Anthropol. 2000;8(1).

  11. Fryar CD, Gu Q, Ogden CL. Anthropometric reference data for children and adults: United States, 2007-2010. National Center for Health Statistics. Vital Health Stat. 2012;11(252):1−48.

  12. Sethi A, Nimbalkar A, Patel D, Kungwani A, Nimbalkar S. Point of care ultrasonography for position of tip of endotracheal tube in neonates. Indian Pediatr. 2014;51(2):119−21.

  13. Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children. Resuscitation. 2015;89:8−12.

  14. Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;341:c5943.

  15. Neunhoeffer F, Wahl T, Hofbeck M, Renk H, Esslinger M, Hanelt M, et al. A new method for determining the insertion depth of tracheal tubes in children: a pilot study. Br J Anaesth. 2016;116(3):393−7.

  16. Seo JH, Hwang SH, Kang JM, Kim CS, Joo YH. Age-related changes of the larynx and trachea assessed by three-dimensional computed tomography in children: application to endotracheal intubation and bronchoscopy. Clin Anat. 2014;27(3):360−4.

  17. Tailleur R, Bathory I, Dolci M, Frascarolo P, Kern C, Schoettker P. Endotracheal tube displacement during head and neck movements. Observational clinical trial. J Clin Anesth. 2016;32:54−8.

  18. Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci. 2014;4(1):65−70.

How to Cite
Ramlan AAW, Sugiharto A, Mutakim A. Accuracy of pediatric advanced life support method for predicting the depth of endotracheal tube in Indonesian children. Med J Indones [Internet]. 2021Jun.11 [cited 2021Aug.6];30(2):123–8. Available from:
Clinical Research