Atlas of Procedures in Neonatology, 4th Edition
- When prolonged positive-pressure ventilation is required
- To relieve critical upper airway obstruction (Fig. 34.1)
- To provide a route for selective bronchial ventilation
- When tracheal suctioning is required to obtain direct tracheal culture
- To assist in bronchial hygiene when secretions cannot be cleared
- When diaphragmatic hernia is suspected
There is no absolute contraindication to intubating a neonate who has one of the above-mentioned indications. In older patients, the presence of cervical injuries is a contraindication to intubation with a laryngoscope; however, because the occurrence of cervical injuries is infrequent in neonates, we consider that endotracheal intubation is associated with less risk than performance of an emergency tracheotomy.
The supplies and equipment necessary to perform endotracheal intubation should be kept together on either a resuscitation cart or an intubation tray. Each delivery room, nursery, and emergency room should have a complete set of the following items.
- Humidified oxygen/air source, blender, and analyzer
- Oxygen tubing
- Resuscitation bag and mask
- Suctioning device, with 10-French (Fr) suction catheters
- Cardiorespiratory monitor
- Pulse oximetry oxygen saturation monitor
- Sterile stylet
- Adhesive tape: Two 8- to 10-cm lengths of ½-in-wide tape, with half the length split and one 10- to 15-cm length unsplit
- Magill forceps (optional for nasotracheal intubation)
- Pediatric laryngoscope with an extra set of batteries and extra bulb
- Miller blade size 1 for full-term infant
- Miller blade size 0 for preterm infant
Straight rather than curved blades are preferred for optimal visualization.
- Modified blade to allow continuous flow of oxygen at 1 to 2 L/min for better maintenance of oxygenation during procedure (1)
- Endotracheal tubes with internal diameters of 2.5, 3.0, 3.5, and 4.0 mm
- Diameter selected for infant size (Table 34.1)
- Length selected for infant's size (2,3 and 4)
In neonates, there is little leeway between a tube that is too high (increased risk for extubation) or too low (increased risk for mainstem intubation or airway trauma). The appropriate length for an endotracheal tube depends on a number of factors, including an infant's size, and it can be quickly and accurately estimated by measuring the nasal–tragus length (NTL) and/or sternal length (STL). The modified prediction formula for insertion by the orotracheal route is NTL or STL + 1. For the nasotracheal route, the formula is NTL or STL + 2 (5).
It is rarely necessary to insert a tube more than 1 to 2 cm below the vocal cords, regardless of the infant's size. Exceptions include the presence of anatomic defects that necessitate a “bypass” airway, such as a tracheal fistula or subglottic obstruction, and when selective bronchial intubation is intended (6). See Appendix D.
- Precautions (Table 34.2)
- Select orotracheal route for all emergency intubations or when a bleeding diathesis is present. Reserve nasotracheal intubation for elective procedures after stabilization
with orotracheal tube, unless oral anatomy precludes oral intubation.
- Prepare all equipment before starting procedure. Keep equipment ready at bedside of patients likely to require intubation.
- Use appropriate-size tubes (Table 34.1). The tube should not fit tightly between the vocal cords to minimize upper airway trauma.
- To minimize hypoxia, each intubation attempt should be limited to 20 seconds. Interrupt an unsuccessful attempt to stabilize the infant with bag-and-mask ventilation. In most cases an infant can be adequately ventilated by bag and mask, so endotracheal intubation can be achieved as a controlled procedure. The one important exception is in a case of prenatally diagnosed or suspected congenital diaphragmatic hernia.
- Recognize anatomic features of neonatal upper airway (Fig. 34.2).
- Ensure visualization of larynx. This is the most important step (Fig. 34.3).
- Have assistant maintain proper position of patient.
- Avoid hyperextending or rotating neck.
FIG. 34.1. A: Vallecula cyst, causing stridor and proximal airway obstruction. B: Endotracheal tube passes beneath cyst. C: Same patient after laser surgical treatment.
TABLE 34.1 Endotracheal Tube Diameter for Patient Weight and Gestational Age
TABLE 34.2 Trouble-Shooting Problems with Endotracheal Intubation
FIG. 34.2. Anatomic view of neonatal upper airway. The glottis sits very close to the base of the tongue, so visualization is easiest without extending the neck.
- Do not use pressure or force that may predispose to trauma.
- Avoid using maxilla as fulcrum for laryngoscope blade.
- Avoid excessive external tracheal pressure.
- Avoid pushing tube against any obstruction.
FIG. 34.3. A: Normal epiglottis obscuring glottis. This amount of clear secretions does not require suctioning for visualization. B:Same airway as in Fig. 34.1 after surgical removal of cyst. Glottic opening is visible just beneath epiglottis. Gentle tracheal pressure or decreasing neck extension while lifting tip of laryngoscope blade will improve visibility.
- Make certain all attachments are secure.
- Avoid obscuring the point of connection of tube and adapter with any fixation device.
- Secure tube carefully in position to avoid dislodgement, kinking, or movement.
- Vary contact point from side to side to prevent damage to developing palate and palatal ridges (7,8,9 and 10).
- Note relationship of head position to intratracheal depth of tube on radiograph (11,12).
- Do not leave endotracheal tube unattached from continuous positive airway pressure; the natural expiratory resistance is lost by bypassing the upper airway.
- Recognize that in neonates, endotracheal tubes are often pushed in too far because of the short distance from the glottis to the carina. Use a standardized graph or location device (2,5).
- Recognize the association of short trachea (fewer than 15 tracheal cartilage rings) with certain syndromes: DiGeorge syndrome, skeletal dysplasias, brevicollis, congenital rubella syndrome, interrupted aortic arch, and other congenital syndromes involving the tracheal area (13).
- Identify and prevent the factors that are most likely to contribute to spontaneous extubation (14).
- Increased secretions
- Necessitating more frequent suctioning
- Loosening of tape
- Infant activity
- Procedures requiring repositioning infant
- Tube slippage
- Technique (See also Endotracheal Intubation on the Procedures DVD, and Appendix D for Techniques of Intubation Specific to Unique Patient Needs)
Orotracheal Intubation (Table 34.2)
- Position infant with the head in midline and the neck slightly extended, pulling chin into a “sniff” position (Fig. 34.4). The head of the infant should be at operator's eye level.
It may be helpful to place a roll under the baby's shoulders to maintain slight extension of the neck.
- Put on gloves.
- Clear oropharynx with gentle suctioning.
- Empty stomach.
- Bag-and-mask ventilate and preoxygenate infant as indicated by clinical condition. Follow heart rate and oxygenation.
FIG. 34.4. Appropriate sniff position for intubation. Note that the neck is not hyperextended; the roll provides stabilizing support.
- Turn on the laryngoscope light, and hold the laryngoscope in left hand with thumb and first three fingers, with the blade directed toward patient.
- Put thumb over flat end of laryngoscope handle.
- Stabilize the infant's head with right hand.
The laryngoscope is designed to be held in the left hand, by both right- and left-handed individuals. If held in the right hand, the closed, curved part of the blade may block the view of the glottis as well as make insertion of the endotracheal tube impossible.
FIG. 34.5. Open the mouth and push the tongue aside with the forefinger while stabilizing the head with the thumb and other fingers of the right hand.
- Open infant's mouth and depress tongue toward the left with the back of right forefinger (Fig. 34.5).
- Continue to steady head with rest of right hand.
- Do not use the laryngoscope blade to open mouth.
- Under direct visualization, insert laryngoscope blade, sliding over the tongue until the tip of the blade is resting in the vallecula (the area between the base of the tongue and the epiglottis) (Fig. 34.6).
In general, the blade tip should be placed in the vallecula. However, in extremely premature infants, the vallecula may be too small, in which case it may be necessary to use the blade tip to gently lift the epiglottis.
FIG. 34.6. Pass the laryngoscope carefully along the finger to the back of the oropharynx.
- Lift the laryngoscope blade to open mouth further and simultaneously tilt the blade tip slightly to elevate the epiglottis and visualize the glottis (Fig. 34.7).
When lifting the blade, raise the entire blade in the direction that the handle is pointing. Do not lift the tip of the blade by using the upper gum line as the fulcrum for a rocking motion; this will not produce a clear view of the glottis and will place excessive pressure on the alveolar ridge, potentially impeding future tooth formation.
FIG. 34.7. With the laryngoscope at the proper depth, tilt the blade with the tongue as the fulcrum; at the same time, pull on the laryngoscope handle to move the tongue without extending the infant's neck. Use more traction than leverage.
- Suction as necessary.
- Have an assistant apply gentle pressure at the suprasternal notch to open the larynx and to feel the tube pass (15).
- Hold tube in right hand with concave curve anterior, and pass it down the right side of the mouth, outside the blade, while maintaining direct visualization (Fig. 34.8).
FIG. 34.8. Visualize the glottis and pass the endotracheal tube into the oropharynx. Keep the tube outside the curve of the laryngoscope blade for better mobility.
- Once the vocal cords and trachea are visualized, insert the endotracheal tube through vocal cords,
approximately 2 cm into trachea or until the tip is felt passing the suprasternal notch by the assistant (Fig. 34.9).
- If the tube appears too large or does not pass easily, decrease angle of neck extension.
- Confirm endotracheal tube position within the trachea (16,17).
- We currently use Pedi-Cap (Nellcore, Waukesha, WI) end-tidal CO2detector to verify the position of the endotracheal tube within the trachea. This technique responds quickly to exhaled CO2with a simple color change from purple to yellow. It also features an easy-to-see display window that provides constant visual feedback with breath-to-breath response (Fig. 34.10).
- While gently ventilating with an Ambu bag, auscultate to make sure the breath sounds and chest movement are equal in both sides of the chest.
- Observe respiratory wave pattern on oscilloscope to determine that artificial breath is at least as effective as spontaneous breath.
- Verify lip-to-tip distance.
FIG. 34.9. A: Pass the endotracheal tube through the glottis to the appropriately predetermined length and remove laryngoscope.B: An assistant applies gentle pressure in the suprasternal notch to open the larynx and to detect when the tube passes into the trachea.
- If the endotracheal tube is correctly placed in the midtracheal region, there should be
- Pedi-Cap response to exhaled CO2by a reversible color change, purple to yellow
- Equal bilateral breath sounds
- Slight rise of the chest with each ventilation
FIG. 34.10. Pedi-Cap CO2 detector. Pedi-Cap is a trademark of Tyco Healthcare Group LP. (Reprinted by permission from Nellcor Puritan Bennett, Inc).
- No air heard entering stomach
- No gastric distention
- Suction endotracheal tube with sterile catheter, following technique described under F.
- Attach appropriate mechanical ventilatory device.
- Adjust required FiO2.
- Secure the tube to the infant's face (Figs. 34.11 and 34.12).
When using adhesive tape, make sure that the face is dried thoroughly to ensure adherence of the tape and to protect the skin. A more permanent fastening can be done later when a radiograph confirms correct placement of the endotracheal tube (18).
- Obtain chest radiograph with head in neutral position, and note the lip-to-tip distance and direction of bevel (Figs. 34.13 and 34.14).
When a correct tube length has been determined for the infant, note the tube marking at the level of the infant's lips.
- Cut off excess tube length to leave 4 cm from the infant's lips and reattach adapter firmly.
If a longer external length is required, before replacing the adapter, slip a short length of a larger endotracheal tube around the narrower tube to prevent kinking, for example, a 6-cm length of 3.5-mm tube over a 2.5-mm tube.
- Reconfirm tube marking at lip regularly, to avoid unnoticed advancement of the tube into the airway.
- Retape tube as necessary to maintain stability.
In neonates, orotracheal intubation is preferred because it is easier and faster to perform and there are few proven advantages to nasal intubations in small infants (19,20). Nasotracheal tubes are preferred in very active infants with copious oral secretions, making it difficult to keep the tube taped in position. When anatomy precludes oral intubation or for oral surgery, nasotracheal intubation may become necessary. Premedication with succinylcholine/atropine or morphine/atropine has been reported to allow a shorter time for intubation, with fewer negative systemic effects (21).
FIG. 34.11. After initially determining that the endotracheal tube is in the correct position, connect the tube to an artificial ventilation source. In the term neonate begin fixation of the tube by painting the philtrum with tincture of benzoin and allowing it to dry. Avoid use of tincture of benzoin in low-birthweight infants; it increases epidermal stripping.
FIG. 34.12. Fixation of tube with half split tape. A: First half of one split tape (1) encircles the tube, and the other half (2) attaches to the upper lip. B: Second split half (3) attaches to the upper lip, while the bottom half (4) encircles the tube.
- Use sterile endotracheal tube. If stylet is used to curve tube, remove it prior to nasal insertion.
FIG. 34.13. Although the carina is usually at the level of T4 on the anteroposterior supine chest radiograph, this relationship may be significantly disturbed by a number of factors, including radiographic technique (x-ray tube position, angulation). For this reason and because the carina is usually easily visualized, as in these cases, one should directly relate the tip of the endotracheal tube to the carina radiographically, knowing the position of the head at the time of film exposure. In both cases, films were taken to verify endotracheal tube position but demonstrated problems with other procedures. A: Appropriate radiographic angle. (Note the oral gastric tube in the esophagus and not reaching the stomach.) B: Slightly lordotic radiographic angle. (Note the central venous line coiled in the heart.)
FIG. 34.14. Sequential radiographs demonstrate the effect of head rotation on bevel direction. A: With the head rotated to the right, the bevel appears to be directed against the tracheal wall. B: The head is rotated to the left, and the bevel is now positioned properly. If the bevel is directed against the posterior tracheal wall in a spontaneously breathing infant, there may be symptoms of tracheal obstruction on expiration. Rather than turning the head to achieve satisfactory position, rotate the endotracheal tube and retape in position.
- If desired, premedicate with atropine (20 mcg/kg) and succinylcholine (2 mg/kg) just before inserting tube. Be prepared to provide assisted bag-and-mask ventilation.
- If orotracheal tube is already in place, release fixation and position at far left of the mouth, to allow continued ventilation during nasotracheal intubation.
- Directly visualize oropharynx with laryngoscope as described previously, taking particular care not to hyper-extend neck.
- Suction oropharynx while keeping laryngoscope in place.
- Insert tube through nostril following natural curve of nasopharynx.
- As tube passes into the pharynx, align the tip with the center of the tracheal orifice, moving infant's head as needed.
- When the tip of the nasotracheal tube appears to be in direct line with the glottis, have assistant carefully withdraw the orotracheal tube.
- Apply gentle pressure over the suprasternal notch and advance tube through cords.
Use of the Magill forceps is often more cumbersome than helpful in smaller infants. A Magill forceps should always be available, but in a properly positioned infant, a curved tube usually passes directly into the trachea without forceps unless the neck is excessively extended, flexed, or rotated. Secure tube and verify position. The length of a nasotracheal tube for correct positioning of the tip in the trachea is approximately 2 cm longer than the equivalent length of an orotracheal tube.
- Tracheal Suctioning
Suctioning of the nose, mouth, and pharynx is potentially quite traumatic in neonates. The same equipment, precaution, and complications apply as for tracheal suctioning. Always suction an endotracheal tube before suctioning the mouth; suction the mouth before the nose.
- To clear tracheobronchial airway of secretions
- To keep artificial airway patent
- To obtain material for analysis or culture
- Relative contraindications
- Recent surgery in the area
- Extreme reactive bradycardia
- Pulmonary hemorrhage
- Oscillatory ventilation
- Saline for instillation into airway
- Saline or water for irrigation of catheter
- Suction catheters
- Available safety features
- Markings at measured intervals
- Microscopically smooth surface
- Multiple side holes in different planes
- Large-bore hole for occlusion to initiate vacuum
- No more than half the inside diameter of artificial airway
- Use 8 Fr for endotracheal tube >3.5 mm.
- Use 5 Fr for endotracheal tube <3.5 mm.
- Modified endotracheal tube adapter that allows passage of suction catheter without disconnecting tube from ventilator (Novometrix C/S Suction Adapter; Novometrix Medical Systems, Wallingford, CT, USA) (22)
- Vacuum source
- Pressure set just high enough to move secretions into suction catheter
- Mechanically controlled pressure source Pressure generated by oral suction on mucus extractors can be extremely variable and dangerously high (23).
- Adjustable vacuum source with specimen trap, tubing, and pressure gauge
- Ventilatory device as indicated
- Warmed, humidified oxygen at controlled level
- Bag with positive end-expiratory pressure device
- When feasible, use two people when suctioning airway, to minimize risk of patient compromise and complications and to shorten time for procedure.
- Determine for each patient if it is better to continue mechanical ventilation during suctioning or to use a sigh with inflation hold after suctioning. Consider effect of interruption of ventilator therapy and loss of lung volume with each catheter passage.
- Allow patient to recover between passages of catheter.
- Stabilize head and airway to prevent tube dislodgement.
- Assess secretions by auscultation and palpation to determine frequency for suctioning.
- Avoid unnecessary suctioning just to follow a schedule.
- Schedule prophylactic suctioning for tube patency only as often as needed to maintain it.
- Consider increase in monitored airway resistance as indication for suctioning (24).
- Readjust humidification as indicated by catheter and volume of secretions.
- Avoid inadvertent suction during insertion of catheter.
Use lowest vacuum pressure effective in clearing secretions within a few seconds.
- Do not insert catheter as far as it will go or until reflex cough occurs. Use prescribed length. Do not suction if catheter is inserted too far; just touching the catheter to the tracheal wall may cause trauma.
- Limit time of insertion and suctioning to least time required to remove secretions.
- Technique for intubated patients
- For artificial airways, use sterile technique with one sterile gloved hand and one free hand.
- Monitor oxygen saturation continuously during suctioning.
- Monitor heart rate continuously.
- It is usually best to remove infant from ventilator and have second person perform assisted ventilation manually, using following guidelines adjusted to individual needs:
- FiO2set at or up to 10% higher than baseline
- Monitor oxygenation. Adjust FiO2to prevent swings in oxygenation.
- Evaluate effect of procedure.
- Peak inspiratory pressure as on ventilator or up to 10 cm H2O higher
- Continuous distending airway pressures same as on ventilator
- Respiratory rate 40 to 60 breaths/min, applying an inspiratory hold intermittently
When there is a high risk of pulmonary air leak as in the presence of significant interstitial emphysema, it may be safer to use a technique of rapid manual ventilation at lower peak pressure instead of sighing with a prolonged inspiratory pressure. In other cases in which loss of lung volume with suctioning is of greater concern, use sigh with a hold on inflation at a rate similar to ventilator. With suctioning, there is a loss of lung volume with a decrease in compliance. The adverse effect persists for a significant time when mechanical ventilation at the same setting is used during and after the suction procedure.
- Determine length of endotracheal tube plus adapter and note on suction catheter as limit of depth of insertion.
- Set vacuum at lowest level to achieve removal of secretions. The level of vacuum required depends on a number of variables, including
- Air tightness of system and fluctuations in generated vacuum pressure
- Accuracy of manometer
- Diameter of catheter (smaller catheter, higher pressure)
- Thickness and tenacity of secretions
- Holding catheter in one hand, moisten tip with water or saline. Note appropriateness of suction level by rate of liquid uptake. Adjust pressure with free hand.
- Open artificial airway with free hand.
- Detach from bag; hold oxygen near end of tube, or
- Open suction port of specialized endotracheal tube adapter.
- With free hand, stabilize airway. Pass catheter down airway to depth limit noted for the patient's endotracheal tube. Do not apply vacuum during insertion (i.e., keep suction control port open).
- Close proximal suction control port and withdraw catheter.
- Limit time for insertion and removal to 15 to 20 seconds.
- Reattach endotracheal tube to bag and ventilate for 10 to 15 breaths or until patient is stable.
- Note oxygenation.
- Note heart rate.
- Note chest excursions.
- If secretions are thick or tenacious, instill 0.25 mL of saline into endotracheal tube and continue ventilation.
- Clear catheter with sterile water.
- Repeat process until airway is clear.
- Fixation Techniques
Many fixation devices and techniques have been described in the literature. None of them can prevent all accidental extubations or malpositions (18,25,26 and 27). Here, we describe a simple and effective method.
- Prepare two 8- to 10-cm lengths of adhesive tape split half of the length and one 10- to 15-cm length without a split.
- Paint skin adjacent to the sides of the mouth and above the lips with tincture of benzoin (Fig. 34.11).
- Allow to dry while holding the tube in place.
- Tape the unsplit end of the adhesive to the cheek on one side of the mouth, and wrap the bottom half clockwise around the endotracheal tube just at the lip. Fold the last 2-mm end of tape on itself to leave a tab for easier removal (Fig. 34.12).
- Secure the other half above the upper lip.
- Repeat the procedure from the other side, reversing the direction of the taping and securing half on that side of the upper lip (Fig. 34.12).
- Secure one end of the long tape to one cheek at the zygoma. Loop the tape around the tube, and secure the other end to a similar point on the opposite cheek.
- Note the markings on the endotracheal tube at the level of the lips and the tape.
- Whenever the tape seems to be loosened from secretions, remove tape and repeat application of benzoin while holding tube at proper lip-to-tip depth.
- Planned Extubation
Various vasoconstrictors and anti-inflammatory medications have been recommended to reduce postextubation stridor and to improve the success of extubation. Systemically administered dexamethasone appears to have very little if any effect in reducing acute postextubation stridor in neonates and children (28,29). Local application of steroids directly to the vocal cords has not been well studied.
- Perform chest physiotherapy and suction prior to extubation.
- Release all fixation devices while holding tube in place.
- Using manual ventilation, give infant a sigh breath, and withdraw tube during exhalation.
- Avoid suctioning during tube withdrawal, unless specifically removing foreign material from trachea.
- Allow recovery time before suctioning oropharynx.
- Keep the inspired gases well humidified.
FIG. 34.15. Subglottic erosion and stenosis after intubation.
- Acute trauma (30,31,32 and 33)
- Tracheal or hypopharyngeal perforation
- Laryngeal edema
- Mucosal necrosis (Fig. 34.15)
- Vocal cord injuries
- Dislocation of arytenoid
- Chronic trauma (31,32,33,34,35,36,37, and 38)
- Cricoid ulceration and fibrosis
- Glottic and/or subglottic stenosis (Fig. 34.15)
- Subglottic granuloma (Figs. 34.16 and 34.17)
- Hoarseness, stridor, wheezing
- Subglottic cyst
- Protrusion of laryngeal ventricle
- Interference by oral tube with oral development (7,8,9 and 10,39,40,41,42, and 43)
- Alveolar grooving
- Palatal grooves (Fig. 34.18)
- Acquired oral commissure defect (Fig 34.19)
FIG. 34.16. Radiographic magnification high-kilovoltage film (2 x) demonstrating an abrupt cutoff of the right bronchus intermedius (arrow) due to an endobronchial granuloma with secondary volume loss at the right lung base. Although these granulomas may be due to endotracheal tube trauma, in this area they are more likely related to suction tube injury. The endotracheal tube is just entering the right bronchus.
FIG. 34.17. Glottic granuloma after intubation. Epiglottis is manually retracted to reveal granuloma below cords. Esophageal opening is clearly visible beneath airway.
FIG. 34.18. Palatal groove after prolonged oral intubation. Such grooves may be seen after prolonged use of endotracheal or oral gastric tubes when the normal forces of the tongue are prevented from assisting palatal development.
FIG. 34.19. Acquired oral commissure defect: a complication of prolonged endotracheal intubation. (Reprinted by permission from
Macmillan Publishers Ltd. Journal of Perinatology. 2005;25:612
FIG. 34.20. Nasal stenosis due to nasal cartilage necrosis following an indwelling nasotracheal tube.
- Posterior cross-bite
- Defective dentition
- Enamel hypoplasia
- Incisor hypoplasia
- Poor speech intelligibility
- Local effects from nasal tube (44,45 and 46)
- Erosion of nasal septum
- Stenosis of nasal vestibule (Fig. 34.20)
- Nasal congestion
- Midfacial hypoplasia
- Otitis media
- Systemic side effects (47,48,49,50 and 51)
- Increased intracranial pressure
- Bradycardia and cardiac arrest
- Misplacements into esophagus or bronchus (52,53) (Figs. 34.21, 34.22 and 34.23)
- Pulmonary air leak
- Loss of tube into esophagus
- Across tracheoesophageal fistula
- Displacement; accidental extubation (54)
- Obstruction (54)
- Kinking, proximally or distally
- Unrecognized disconnection from adapter or pressure source
FIG. 34.21. Radiograph demonstrating an endotracheal tube malpositioned in the bronchus intermedius, with resulting atelectasis of the right upper lobe and of the left lung. There is marked overaeration of the right middle and lower lobes but no pneumothorax as yet.
- Rupture of endotracheal tube (55)
- Foreign body from stylet left unrecognized in airway
- Swallowed laryngoscope light (56)
- Postextubation atelectasis (54)
- Increased airway resistance increasing work of breathing (57,58)
FIG. 34.22. Relatively uncommon malposition of an endotracheal tube in the left bronchus with atelectasis of much of the right lung.
FIG. 34.23. A: Radiograph suggesting that the endotracheal tube is in the right mainstem bronchus. Note the gaseous distension of the stomach and intestine. The wavy tube on the right is external. B: In the lateral view, the same endotracheal tube is easily seen to be in the esophagus (arrowheads) posterior to the trachea (arrows).
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