Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Article
  • Published:

Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate

Abstract

Objective:

To determine accuracy of the 7-8-9 Rule in a cohort of neonates.

Study Design:

This study was cross-sectional in design. Seventy-five consecutive neonates who required oral intubation from June 2004 to November 2004 for cardiopulmonary failure, respiratory distress, or surfactant administration were the subjects of this study. The initial endotracheal tube (ETT) depth of insertion was determined using either an estimated birth weight or actual weight in the 7-8-9 Rule calculation followed by auscultation and subsequent adjustment if necessary. Midtracheal position was identified as the point halfway between the inferior clavicle and carina on a chest radiograph. The initial depth was compared to the midtracheal depth to determine clinical accuracy of the 7-8-9 Rule. The depth predicted by the 7-8-9 Rule was also calculated using only actual weights. This predicted depth was compared to the midtracheal depth to determine true accuracy of the 7-8-9 Rule. Accuracy was determined using mean paired differences with 95% confidence intervals (CI) between initial or predicted depth and ideal, midtracheal ETT depth. Linear regression was used to adjust for confounding variables.

Results:

Mean (range) gestational age was 32 weeks (23 to 44 weeks) and weight was 2001 g (490 to 4400 g). Eighteen (24%) infants weighed 1000 g or less, 20 (27%) weighed between 1001 and 2000 g, 21 (28%) weighed between 2001 and 3000 g, 15 (20%) weighed between 3001 and 4000 g, and one (1%) weighed more than 4000 g. Thirteen of the 18 extremely low birth weight infants weighed <750 g. The initial depth of insertion was 0.004 cm above midtracheal position (95% CI −0.13 to 0.14, P=0.96). After controlling for head position, the initial depth did not significantly differ from the midtracheal position among weight groups. Predicted depth using the 7-8-9 Rule placed the ETT 0.12 cm above midtracheal position (95% CI −0.30 to 0.06, P=0.20). However, after controlling for head position, the 7-8-9 Rule positioned the ETT significantly below midtracheal position in infants weighing <750 g (mean 0.62 cm; 95% CI 0.30 to 0.93, P=0.002).

Conclusions:

The 7-8-9 Rule appears to be an accurate clinical method for endotracheal tube placement in neonates weighing more than 750 g. When the 7-8-9 Rule is applied to infants weighing <750 g, caution is warranted. The current rule may lead to an overestimated depth of insertion and potentially result in clinically significant consequences.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1

Similar content being viewed by others

References

  1. Kattwinkel J, Denson S, Zaichkin J, Niermeyer S . Textbook of Neonatal Resuscitation. 4th edn, American Heart Association: Dallas and American Academy of Pediatrics: Elk Grove Village, IIL, 2000. pp 5.1–5.34.

    Google Scholar 

  2. Hageman JR, Slotarski K, Casserly G, Hawkins H . Pulmonary care. In: Goldsmith J, Karotkin E (eds). Assisted Ventilation of the Neonate. W.B. Saunders Publishing Co.: Philadelphia, 2003. p 96.

    Google Scholar 

  3. Carlo WA, Martin R, Fanaroff A . Assisted ventilation and complications of respiratory distress. In: Fanaroff AA, Martin RJ (eds). Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. Mosby Inc: St. Louis, 2002, pp 1021–1025.

    Google Scholar 

  4. da Silva O, Stevens D . Complications of airway management in very-low-birth-weight infants. Biol Neonate 1999; 75: 40–45.

    Article  CAS  PubMed  Google Scholar 

  5. Tochen ML . Orotracheal intubation in the newborn infant: a method for determining depth of tube insertion. J Pediatr 1979; 95: 1050–1051.

    Article  CAS  PubMed  Google Scholar 

  6. Niermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B, Zideman D et al. International Guidelines for Neonatal Resuscitation: an excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines. Pediatrics 2000; 106: E29.

    Article  CAS  PubMed  Google Scholar 

  7. Vohr BR, Wright LL, Dusick AM, Mele L, Verter J, Steichjen JJ et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993–1994. Pediatrics 2000; 105: 1216–1226.

    Article  CAS  PubMed  Google Scholar 

  8. Dawson-Saunders B, Trapp RG . Association and Pediction. In: Basic and Clinical Biostatistics. Appleton and Lange: Norwalk, CT, 1994, p 176.

    Google Scholar 

  9. Lee YS, Soong WJ, Jeng MJ, Cheng CY, Shen CM, Sun J et al. Endotracheal tube position in pediatrics and neonates: comparison between flexible fiberoptic bronchoscopy and chest radiograph. Chin Med J 2002; 65: 341–344.

    CAS  Google Scholar 

  10. Lange M, Jonat S, Nikischin W . Detection and correction of endotracheal-tube position in premature neonates. Pediatr Pulmonol 2002; 34: 455–461.

    Article  PubMed  Google Scholar 

  11. Jain A, Finer NN, Hilton S, Rich W . A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates. Resuscitation 2004; 60: 297–302.

    Article  PubMed  Google Scholar 

  12. Hill A, Perlman JM, Volpe JJ . Relationship of pneumothorax to occurrence of intraventricular hemorrhage in the premature newborn. Pediatrics 1982; 69: 144–149.

    CAS  PubMed  Google Scholar 

  13. Linder N, Haskin O, Levit O, Klinger G, Prince T, Naor N et al. Risk factors for intraventricular hemorrhage in very low birth weight premature infants: a retrospective case–control study. Pediatrics 2003; 111: e590–e595.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J Peterson.

Additional information

There was no financial support provided to the authors for this research.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Peterson, J., Johnson, N., Deakins, K. et al. Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate. J Perinatol 26, 333–336 (2006). https://doi.org/10.1038/sj.jp.7211503

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/sj.jp.7211503

Keywords

This article is cited by

Search

Quick links