I was very fortunate to do my fellowship in neonatology with Neil Finer. One of the (very many) things which he taught me, about the 3rd day of the fellowship I think, was how to determine ETT position. He showed me this technique, with a finger in the suprasternal notch, moving the tube slightly, you can determine if the ETT is in good position. I have used it ever since and tried to teach others. The way I do it is to make sure the infant’s head is in neutral position, then put an index finger in the notch, and you should be able to feel the firm resistance of the tube. Then you slowly pull the tube back until you feel the tip. Then advance the tip of the tube until it is just as far you can feel, just above the manubrium. I have never performed a study of this, but I have never had an endobronchial intubation in many years using this technique. It is very simple and accurate in small preterm infants, but a little more difficult to be sure of the detection of the tube tip in a large term baby.
Several years later Neil published a randomized study demonstrating the utility of the technique (Jain A, Finer NN, Hilton S, Rich W. A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates. Resuscitation. 2004;60(3):297-302).
In a new trial, (Saboo AR, Dutta S, Sodhi KS. Digital palpation of endotracheal tube tip as a method of confirming endotracheal tube position in neonates: an open-label, three-armed randomized controlled trial. Pediatric Anesthesia. 2013;23(10):934-9) infants were randomized to have either tube position determined by either a weight based calculation, calculation plus palpation by ‘specially trained neonatology fellows’ or calculation plus palpation without extra training. There were many fewer malpositioned tubes in the second group.
This technique is simple, easy to learn, non-invasive and quick. It can practically eliminate endobronchial intubations, and ensure that surfactant is delivered via a tube above the carina. It should be more widely taught and used.