AIRWAY MANAGEMENT DURING

CARDIOPULMONARY RESUSCITATION
IN FILIPINOS: A NEW PERSPECTIVE
Ma. Minerva Patawaran-Calimag. M.D. *
Julieta Canlas-Paiarillo, M.D. *
Endotracheal intubation may be a life saving proce-
dure. In fact it remains the method of choice in main-
taining an airway in advanced cardiac life support. In-
deed, the cuffed tracheal tube has proven itself to be an
invaluable tool during cardiopulmonary resuscitation.
In the hands of the inexperienced, however, it can be a
harbinger of disaster. The choice of the correct size and
type of tube is only one aspect in the management of
the compromised airway. The length of the airway is
as lmportant in so far as ignorance of this fact can lead
to inadvertent endobronchial intubation with consequent
hypoxemia. This study therefore aims to establish stand-
ards for determining tracheal tube length in Filipino
adults with the use of several anthroprometric data. After
studying ninety-eight randomly selected Filipino adults,
the following conclusions were reached: I) The average'
optimal orotracheal tube length were 22.13 ern,
. SD1.02 cm for males and 21.17 em, SD1. 74 ern for
females; 2) There are significant statistical correlations
between optimal orotracheal tube length and the con-
sidered factors, namely height, cricoid to xiphoid tip
distance and length of the third finger; 3) The maximum
safe length of orotracheal tube in adult Filipinos can be
predicted as follows: Orotracheal tube - cricoid to
xiphoid distance minus 2 ern, or three times the length
of the third fmger minus I em. Nasotracheal tube -
cricoid to xiphoid tip distance, or three times the
length of the third fmger plus I ern.
In the last quarter of the century, advances in the
basic understanding, techniques, teaching and practice
of cardiopulmonary resuscitation have resulted in
saving countless lives. Initial measures to establish
artificial ventilation and circulation are the same, whe-
ther performed by physicians or lay rescuers, and
whether performed in a hospital or in any other loca-
tions.
In most instances, respiration stops before circula-
tion. Since any other measures will be ineffective in
the absence of pulmonary ventilation, respiration
should always be checked. first.
Because of the difficulties, delays and cornplica-
tions in the proper placement of an endotracheal tube,
its use during cardiopulmonary resuscitation is restric-
ted mainly to medical personnel or professional health
personnel who are highly trained in the said procedure.
"Santo Tomas University Hospital. Section of Anesthesia,
Division of Surgery
JMMSI Vol. XXII No.4-6 April-8eptember, 1986
Even among the experienced, misconceptions still
abound as to the choice of the proper type, size and
length of the endotracheal tube to use in a given patient.
Ignorance of important anatomical considerations
can lead to immediate or delayed complications. The
National Conference on Cardiopulmonary Resuscita-
tion ani! Cardiac Care (1979) 1 in affirming the recom-
mendations set forth by its Steering Committee in
1974
2
has stated that 8.0-8.5 mm LD. endotracheal
tubes be used for women and 8.5-9.0 mm LD. tubes for
men. Since then, several foreign authors have shown
evidence that the above recommendations are too large
in many cases even for Caucastans.' Standards of sub-
glottic and tracheal diameters have been set by one of
the authors in two previous The choice of
the correct size and type of endotracheal tube, how-
ever, is only one aspect in the management of the
compromised airway. The length of the airway from the
teeth or nose through the mouth, pharynx and finally
into the trachea has likewise been discussed in foreign
literature but no mention of it has yet been published
in the local literature.
In an attempt therefore to set standards of endo-
tracheal tube length among Filipinos, this study was
undertaken aimed at estimating the distances from
the base of the nose, or from the upper anterior incisor
teeth to just above the carina.
The data on Filipino subglottio- and tracheal dia-
meters and their anatomic correlates previously re-
ported
4,s
will also be reproduced here to point out
possible dimensional interrelationships of the upper
airway. Aside from pure anthropometry, such inform-
ation has potential applications to studies in pulrno-
nary resuscitative physiology and anesthesiology. If
certain critical dimensions and their interrelationships
are known, and further if they can be used as a basis
of prediction, many problems in the areas mentioned
can be more precisely defined for study. Of course,
there is a certain general interest in the knowledge of
measurements of the human body for its own sake.
MATERIALS AND METHODS'
The data for this study were obtained from ninety
eight randomly selected adult patients scheduled for
operation under general anesthesia via the orotracheal
or nasotracheal route at the Santo Tomas University
109
FIG. I. Number of subjects by gender and age group.
TABLE I. Summary of the data for Filipino subjects (N '" 981.
so
MEAN AGE - 35.7 vrs.,
SO 14.6 VI'S.
\
,
\
\
\
___ males
_femalet
D 1 subject
40 00
Age (years I
t,
o \
I '
o \
I \
20
4
2
B
'0
"0 B
RESULTS
Figure I depicts the number of subjects by gender
and age group. The age range was 15 to 78 years with an
overall mean age of 35.7 years, SD14.6 years. A sum-
mary of the data and measurements obtained on 98
Filipino adults are presented On Table l.
The mean optimal orotracheal tube length were 22.13
ems, SD1.02 ems for the male subjects, and 21.17 ems,
SD1. 74 ems for the female subjects.
males and females separately. Regression lines were
derived using the least squares method.P:
7
To determine what effect advanced age might have on
the observed differences between the distance from the
superior border of the cricoid cartilage to the tip of the
xiphoid process and the orocarinal distance, data for
subjects aged 50 and below Were compared with those
from 51 years old and over. Student's "T" test was used.
For all statistical analysis a p value less than 0.0 I was
considered significant.
Number Numt.r
.,
..
Subj""rs Me.., S,D, Subjeo:u "In S.D.
AgIt tv..rtl
"
36.69 1<1.58 ee 40.11 1129
Hoight (eml
"
160.70 1 5B7
"
155.62
,...
Cri>!d Clnllage
10 Xiphoid Tip
Obllnee (em)
"
24.15 0.99 ee 22-1llI 1,32
Length 01 the
7.73 0.45 Middle Finger lem) ea es 7.40 0.42
Optlmel
Orotrach.l
Twe Llngth (eml .. 22.13 1.02 eo 21.11 1,74
Opdmll
NlIOtrach...1
Tube Length (em)
,
26.80 0.11
,
25.32 0.30
Hospital, Clinical Division, from February to March,
1985.
The study included fifty-two males and forty-six
females.
All measurements were made with the patient lying
supine on the operating table with the head in the
neutral position. Before intubation, the following
parameters were determined: height, cricoid to xiphoid
distance and length of the third finger. Measurements
were made to the nearest 0.5 em.
Cricoid to xiphoid distance was measured along the
body surface from the superior border of the cricoid
cartilage to the tip of the xiphoid process, using a
measuring tape.
Third finger length was measured on the palmar
surface of the hand from the metacarpophalangeal joint
crease to the finger tip.
Prior to intubation, the endotracheal tube and its
cuff were checked for defects. The tube is then lubrica-
ted with lidocaine jelly. Patients were preoxygenated
and general anesthesia induced with thiopental sodium,
3-5 mgs/kg BW intravenously. After loss of eyelid re-
flex, 1-2 mgs/kg BW of succinylcholine is administered
to facilitate intubation. Intubation was then carried
out with the appropriate size of tracheal tube.' Deli-
berate endobronchial intubation was done after which
the tube was gradually withdrawn until breath sounds
are equal in all areas of the lungfields. The cuff is then
inflated to minimal occlusive (i.e. that cuff volume
which is needed to produce an airtight seal between
trachea and cuff).
The level of the tube was verified further by perform-
ing the following maneuvers: I) constant pressure is
applied to the pilot balloon of the inflated cuff by the
index finger and the thumb of one hand, while the other
hand palpates the trachea between the cricothyroid
cartilage and the suprasternal notch, where a distinct
increase in pressure could be felt over the inflated cuff;
2) injecting one milliliter of sterile saline into the pilot
balloon and the balloon compressed and released gently
between the fingers and auscultating for the presence
of crepitus over the suprasternal notch at the approxi-
mate level of the cuff.
These maneuvers indicate that the cuff of the endo-
tracheal tube is located below the vocal cords and several
centimeters above the carina. Added documentation is
acquired in those patients requiring chest x-ray post-
operatively, showing the exact position of the tip of the
endotracheal tube with the head in neutral position. .
Being satisfied with the position of the tube an oral
airway is inserted and the tube fixed into position by
means of adhesive tape. The depth of tube insertion is
determined by the centimeter markings on the tube at
the level of the upper incisors, or in edentulous patients
at the external surface of the upper gums. The length
of the tube is then compared with the various anthro-
pometric measurements obtained, i.e, height, third
finger length and cricoid cartilage to xiphoid till
distance.
Statistical analysis were done using the Pearson
product moment correlation coefficient matrices. A
rnatix was computed for the entire population and for
110
JMMSI Vol. XXII No. 4-5 April-September. 1986
FIG. 3. Correlations and regressions of orotraeheal tube length
with cricoid cartilage to xiphoid tip distance.
Figure 3 illustrates the optimal tube length versus
cricoid to xiphoid process distance for each of the sub-
jects. The regression line for the entire population
(N=84) was expressed by the equation Y = O.969X-
1.42. The equations Y =O.706X+4.80 and Y=O.994X
- 1.84 represented the regression lines for male and
female subjects, respectively.
26 24 22
REGRESSIONS
Cricoid - Xiphoid O!ltllnce
-- all meles and ferrel" IN84)
malesIN -44)
- ~ - females IN. 40)
20
o male.
o females
18
28
18
24
~
} 22
~
..
l
20
!
o
Correlative and Predictive Factors of Optimal Endo-
tracheal Tube Length.
Age. Age had a very low correlation with optimal
tube length. When data from subjects aged 50 and below
were compared with data from those aged 50 and over
using the Student's 'T' test, the p value obtained was not
significant (p value> 0.50).
Sex. There was a highly significant level of correla-
tion between sex and optimal orotracheal tube length.
Female subjects were shorter and required shortercoder
tracheal tubes than their male counterparts.
Height. The mean height for males was 160.70 ems,
SO5.87 ems (63.27 inches, SO2.3 inches), and for
females, 155.62 ems, S06.54 ems (61.27 inches,
SO2.57 inches). A significant correlation was found
when the optimal tube length was compared with the
height. When broken down by sex however, the correla-
tion was better for males than for females.
Third "Inger Length The length of the middle finger
correlated wei! with optimal tube length. The orotracheal
lube length was usually less than three times the length
of the middle finger in centimeters. The meandifference
was 0.5 em in males and0.9 em in females.
Figure 2 plots the optimal tube length versus third
finger length for each of the subjects. The regression
line for the entire population (N=84) was expressed by
the equation Y = 1.75X + 8.2. Regression lines were
plotted separately for male subjects (Y = 1.58X + 9.67)
and female subjects (Y = 1.65X +8.7).
FIG. 2. Correlations and regressions of crorrecheat tube length
with length of the middle finger.
26
24
22
20
males
o females
REGRESSIONS
-- all malesand femllleilN - 84)
.... - - males IN -44)
-.- females (N. 40)
The correlation coefficients and the levels of signifi-
cance between optimal endotracheal tube length and the
various anthropometric measurements considered are
listed in Tables II and III.
Because of the scarcity of patients subjected to naso-
tracheal intubation during the study period, no signifi-
cant statistical analysis can be done. Inspection of the
data obtained, however, revealed that on the average,
nasotracheal tube length approximate the cricoid car-
tilage to xiphoid tip distance.
TABLE II. Correlations of considered factors with oPtImal
orotracheal tube length in 84 Filipino adults.
Cricoid Cartilage to Xiphoid Tip Distance. The mean
distance from the superior border of the cricoid cartilage
to the xiphoid process for the male subjects was 24.15
ems. SD 0.99 ems, and for the female subjects, 22.98
ems, SO1.32 ems.
The orotracheal tube length was usually less than the
distance from the cricoid cartilage to the tip of the
Xiphoid process. The mean differences was 2.5 ems in
males and 2.0 ems. in females.
JMMSI Vol. XXII No. 4-5 AprilSeptember.1986
Middlo Finger Length fern)
'8
6.5 7.0
7.5 8.0 8.5
Orotracheal
tub81ength
Age
O . ~
Height 0.300
Length of Middle Finger 0.860"
Cricoid Cartilage to
Xiphoid TIp Distance 0.974
Up value ( 0.001, highly 5.lgntficant
"p value ( 0.01, significant
111
TABLE III. Correlations of factors with optimal
orotracheal tube length in Filipino male (N = 44) and female
IN =40) subjects.
Orotracheal
MALES tube length
Height
0.783-
Length of Middle Finger
0.863'
Crjcoid Cartilage to
Xiphoid Tip Distance
0.779'
Orotracheat
FEMALES tube length
Height
0.580'
Length of Middle Finger 0.575'
Cricoid Cartilage to
Xiphoid Tip Distance 0.987-
"p value ( 0.001, highly significant
DISCUSSION
Opening the airway and restoring breathing are the
first steps in artificial ventilation during cardiopulmo-
nary resuscitation. Oxygenation of the lungs by simple
airway adjuncts should precede attempts at tracheal
intubation." Adequate lung inflations interposed be-
tween external chest compressions require high pharyn-
geal pressures. This factor promotes gastric distention
which elevates the diaphragm and interferes with ade-
quate lung inflation. Gastric distention likewise pro-
motes regurgitation with the potential hazard of aspira-
tion of gastric contents into the lungs. Therefore, as
soon as is practical, the trachea should be intubated.
This isolates the airway, diminishes the chances of
aspiration and ensures the entry of a high concentration
of oxygen to the lungs. With a cuffed endotracheal
lube. it is easier to provide adequate ventilation during
cardiopulmonary resuscitation than with mouth-to-
mouth, mouth-to-mask, or bag-valve-mask technique,
The indications for endotracheal intubation include
the following: I) inability of the rescuer to ventilate the
unconscious patient with conventional methods, 2)
inability of the patient to protect his own airway (coma,
areflexia), or 3) the need for prolonged artificial ventila-
tion.'
Indeed, the cuffed endotracheal tube has proven it-
self to be an invaluable tool during cardiopulmonary reo
suscitation. In the hands of the inexperienced and the un-
initiated, however, it can be a harbinger of disaster even
as soon as the choice of a specific type and size of endo-
tracheal tube is made.
Many authors have reported on the complications of
endotracheal Too large a tube
can result in pressure necrosis most especially in the
subglottic region. The cricoid cartilage surrounding
completely the subglottic region forestalls any external
expansion of the swollen surfaces which can only expand
internally, giving rise to a dangerous airway obstruction.
The cuff On the endotracheal tube poses yet another
problem. The high pressure, low volume cuffs have been
112
unequivocally implicated as the cause of pressure nee-
rosis in the trachea. During prolonged intubation, how-
ever, a discrepancy between tracheal size and endo-
tracheal cuff size may result in increased tracheal
damage even with the use of low pressure, high volume
cuffs. Damage can Occur due to overinflation causing
excessive lateral tracheal wall pressure herniation of the
redundant cuff over the end of the tubed Or actual
collapse of the endotracheal tube lumen with con-
sequent airway obstruction. Underinflation of too large
a CUff, on the other hand, can displace the tip of the
tube towards one side of the trachea especially in non-
circular tracheas wherein they cause noncircumferential
erosions. At times, floppy cuffs may be thrown into
double folds, thus allowing aspiration by the channeling
of liquids through the folds. This is especially true of
cuffs with thickness of more than 0.1 rum.
18
Aside from the problems associated with the external
diameter of the tube and the cuff; another dreaded
complication that can arise following intubation is the
inadvertent insertion of the tube down to the level
of the carina or even into a mainstem bronchus. Often,
an "airway" and ventilation. are established under
emergency conditions by an efficient well-informed
team which disperses when the emergency is over. While
this team may be familiar with the complications. of
intubation - ventilation, those charged with subsequent
care of the patient are commonly less so. Or with ven-
tilation apparently well controlled, attention may be
diverted to other acute problems of the patient's care.
When respiratory distress recurs some hours later, the
role of the airway itself in producing the symptoms
may not be recognized. Endobronchial intubation often
causes a moreorlesscompletetermination of ventilation
in the opposite lung which is thus converted into a
great shunt unit. The shunting of venous blood through
the poorly ventilated or nonventilated lung results in
severe hypoxemia. When imposed on a serious cardio-
pulmonary dysfunction, time is of the essence and any
delays may lead to rapid deterioration and death. Acci-
dental right mainstem bronchus intubation has been
implicated as a cause of respiratory distress in about
1025% of intubated patients. Complications noted
were left-sided atelectasis,19 ,20,21,22 right-sided tension
pneumothorax, or right upper lobe atelectasis.
23
The tube may go down into a bronchus as a result
of the weight of the attachments or from frequent
suctioning if the tube is not firmly anchored. Also,
change in the position during the emergency period
can cause the tube to move up or down in the trachea.
It has been demonstrated that after an accurate
intubation of a patient in the supine position, a change
to the Trendelenburg tilt will result into an upward
shift of the carina with impairment of left lung ven-
tilation.
24
Conrardy et a1
25
has shown that even flexion
of the head may cause the tip of the tracheal tube to
move an average of 1.9 em. towards the carina, while
extension of the head may cause it to move 1.9 em.
away from tlie carina, i.e., regardless of the route of
intubation (oral vs. nasal).
Conversely, failure to place the tracheal tube several
centimeters beyond the vocal cords may result n
inadvertent extubation, vocal cord paralysis, laryngo-
JMMSI Vol. XXII No.4-6 April-September, 1986
spasm and aspiration pneumonia.
9
, 24 , 25
Determining proper tube location has been the sub-
ject of many thesis in the past. Among the recorn-
mended maneuvers include I) placement of the endo-
tracheal tube- under direct vision I to 2 ern. below the
vocal cords.?" 2) confirmation by auscultation for
equality uf breath sounds in all areas of the lungfields,27
3) technique of deliberate endobronchial intubation
with gradual withdrawal of the tube to 1 to 2 em. be-
yound the point at which breath sounds are bilaterally
cqual,27 4) rapid inflation and deflation of the cuff
with palpation for a change in pressure on the trachea
just above the suprasternal notch,'S ,'9 ,30 5) applying
a constant pressure to the pilot balloon of the inflated
cuff by the index finger and the thumb while the trachea
is palpated,'S 6) injecting one I ml of sterile saline into
the partially inflated pilot balloon and listening for
crepitus at the level of the cuff in the trachea while the
pilot balloon is being between the fingers,30
7) chest roentgenogram, ,)j 8) using an eletromag-
netic sensing device,32 9) detecting for chanfes in end-
tidal CO, by continuous mass spectrometry. 3 Some of
these methods, however, are either complicated, incon-
venient, expensive, invasive and impratical. In essence
therefore, it appears beneficial to utilize a combination
of common sense with simple methods to verify proper
positioning of an endotracheal tube. The only ultimate
guarantee of proper tube placement is the chest roent-
genogram and whenever doubt exists, it should be
requested. The maximum safe insertion of a tube in
adults should not exceed beyond T, leveL"
In this world where nature creates nothing to a stand-
ard size. man since the earliest time has used his own
body as the basis for measurements. From hereon, the
concept of anatomic correlates and anthropometric
measurements have evolved and the orocarinal and
nasocarinal distances in man is no exception. Several
authors have noted the "correct" length of orotracheal
and nasotracheal tubes to use in infants and child-
ren,34 ,35 ,36.37,38,39,40,41 and in adults.
42
,43
As early as 1907, Jackson has reported the straight
line distance from the upper anterior teeth to the
carina measured along a bronchoscope to be 27 em.
in men and 23 em. in women. Hewer reported the
pathway of inspired gas from the anterior teeth to the
carina to be 26 em. in length. Gillespie, in 1948, sug-
gested that the length of an endotracheal tube be
selected by placing the tube alongside the patient's
neck whereby its tip should not extend beyoml the
angle of Louis, the anatomical landmark for the bifurca-
tion of the trachea/"
Schellinger, in 1964, determined airway length to the
bifurcation of the trachea on patients for autopsy.
He has noted a positive correlation between the distance
from the superior border of the cricoid cartilage to the
tip of the xiphoid process with the orocarinal distance.
Whereas the diameter of the criooid and the trachea
can be redicted accurately in fresh cadaver speci-
mens
3,',
the same cannot be said of tracheal length.
The trachea appears to. be longer in life than at post-
mortem, mainly because of the elastic recoil of the dia-
phragm making interpretation of these data difficult.
Fearon and Whalen's stud y3S with living subjects (1965)
demonstrated the unreliability of data obtained in
cadavers.
FIG. 4. An algorithm for airway management In the acutely injured patient.
i -ICAlCOTHYFlOlDOTOMyl
I
i
,
r
,
,
!
i
,
I
....
,,-,....
I
'\e NASOTRACH'"
- INTU8ATION
:::7::' -6- BAO MASK CWvIQl /
--. .pl ....
a/T \
Ia.::-:. -61-L-_"":':':":"'.J- ,,,
.. ---- =.::.. _19_
SUPPLEMENTAL
OXYGEN
Trwchal tr-.ctlon
or HYlfW anterior
Injury
X"-Vttudl..
Qlal nlm
c.rvk:IlqoIne
-....
o'll'\Iury
I
o I.e.... 01 conad ........
o V.nllinian
oO"Y....1on
o Aff-.r _ _ I or
Imrni.... nl
I TRACHEOSTOMY I
JMMSI Vol. XXII No. 4-6 April-September, 1986
113
FIG. 5, Factors to consider In airway management of the acutely injured Filipino patient.
o Cricoid to Jdphofd
di$unaJncm
..
taller then 160 em (5'3'" --- '.0 mm 1.0.
BuIld on height end "
Ieller Ihlln 145 em 14'9", 6.5 mm I.D.
shorter then 145 em 14'9'" --- B.Omm I.D.
shorter then 160 em 15'3'" 6.5 mm 1.0.
Bned on Lllnglh of the Third Finger
USE APPROPRIATE SIZE
OFENOOTAACHEALTUBE
Mo'a
oLength of third finger In em 1.0. of tutMlln mm
ORAL ROUTE
o Crl<;oidto .Iphoid - 2 em
dln,nee jn ern
INSERT ENDOTRACHEAL TUBE
TO CORRECT DEPTH
....

I'ORTEX
SHILEY
AM/NCC
AM/NCe
"ENDOTRACHEAL TUBE FIT"
E.tefNlltubt Cuff
diemewr I ,Orcumterwnee
epprOll 0.667
USE pvclpolVllinylehlortdel
ENDOTRACHEAL TUBE WITH A
HIGH COMPLIANCE, LOW PRES.<;URE
CUFF
'" /
I'OATEX
SHILEY
/ -,
" /
RUSCH
r&d rubber

ORAL
INTUBAnON
NASOTRACHEAL
INTAUBAnON
o 13. Length of third! + 1 em
f1nglllrin cm
a (3. Length of thlrdl - 1 em
"nger in em
AUSCULTATE CHEST FOA EQUALITY OF
BREATH SOUNDS
More recently, Saha
42
recommended a method for
determining correct tube length' for adult Caucasians
based on knuckle distance (KD), measured from the
lateral border of the second to the medial border of
the fifth metacarpophalangeal joint, and the orbito-
external auditory meatus distance (OEAMD), measured
from the outer canthus of the eye to the center of the
external auditory meatus. In a predominantly female
population. he noted that a measurement of 2.5 x KD
or OEAMD will approximate closely the distance
between the incisors and a point just above the carina.
The interchangeability of these two measurements
though, is limited when applied to Orientals, Filipinos
included, in whom the OEAMD may be greater than KD.
It is noted that none of the studies so far mentioned,
tried to consider the possibility of whether or not the
orocarinal or nasocarinal distance have any constancy
of relationship with either the cricoid or tracheal dia-
meters which are critical factors to consider in the
choice of an endotracheal tube to use in a given patient.
This premise and the fact that this investigation has
never been undertaken among Filipinos before, provided
the impetus for this study.
Age has generally bccn used as the basis to predict
tube length in infants and children.
4o
It becomes less
reliablc for comparison however, after the first decade
114
of life. In this study among Filipino adults, age has a
very low correlation with the optimal orotracheal tube
length, further attesting to the fact that degenerative
changes during the process of aging does not in any way
affect the distance from the superior border of the
cricoid cartilage to the xiphoid process nor the optimal
tube length.
Height has an equivocal correlation with optimal
orotracheal tube length. Vinen broken down by sex,
however, correlation was found to be higher in males
than in females. As compared to body weight, the height
of the patient is much easier to measure, even in the
seriously ill who are usually recumbent. The height is
also a more or less constant factor when compared
to weight, which can vary widely with the dietary habits
of the patient.
The distance from the superior border of the cricoid
cartilage to the tip of the xiphoid process was usually
more than the optimal orotracheal tube length in Fili-
pinos, by 2 centimeters. Therefore, we can safely say
that when 2 cm. is subtracted from the cricoid to
xiphoid distance, the value obtained is an estimate
of the maximum safe length for orotracheal tube in
all measured subjects.
During cardiopulmonary resuscitation however, the
use of height and cricoid to xiphoid distance may be
JMMSI Vol. XXII No. 4-5 April-September, 1986
limited since the chest is often blocked by other resus-
citators applying external chest compressions.
In a previous study by one of the authors,' it was
found that the third finger length has a high correlation
with the cricoid ring size, thus making it an invaluable
reference in the choice of the proper size of endo-
tracheal tube to use among Filipino adults. In an emer-
gency, the length of the third finger in centimeters
corresponds well to the correct tube size (internal dia-
meter) in millimeters, that a tube may be selected on
that basis. For example, if the third finger length is
6.7 crn., then a 7 mm. internal diameter endotracheal
tube should be used. In the present study, an attempt
was made to correlate this anthropometric measure-
men t with the optimal orotracheal tube length. The
results indicate that when one centimeter is subtracted
from the product of three times the length of the third
flnger, the value obtained corresponds well to the
optimal oro tracheal tube depth calculated for each
patient.
CONCLUSIONS AND RECOMMENDAnONS
On the basis of the foregoing data; we can therefore
conclude that a significant statistical correlation was
obtained between optimal orotracheal tube length and
the considered anthropometric measurements namely,
height, cricoid to xiphoid distance and the length of
the third finger, thus making them good predictors
of airway length in Filipino adults. The maximum safe
length for endotracheal tubes in Filipino adults are as
follows:
Orotracheal tube:
a) Cricoid to xiphoid distance (em) - 2 em.
b) (Third finger length in em x 3) - I em.
Nasotracheal tube:
a) Cricoid to xiphoid distance in em.
b) (Third finger length in em x 3) + 1 em.
Cognizant therefore of the standards set forth in this
study and those of two previous studies among Fili-
pinos
4,s
a more rational approach to airway manage-
ment during cardiopulmonary resuscitation canbe done.
SUMMARY
A method for the predetermination of the maximum
safe length of orotracheal and nasotracheal tubes in Fili-
pino adults is presented.
Correlations of such factors, i.e. age., sex, height. cri-
coid to xiphoid distance and third finger length with
optimal orotracheal or nasotracheal tube length were
computed, andconclusions were derived accordingly.
A review of the literature on the complications asso-
ciated with inadvertent endobronchial intubation
were presented and the importance of predetermination
of the tube length in prolonged intubation is crnpha-
sized.
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116 JMMSI Vol. XXII No.4-6 April-September, 1986