A child presented with severe respiratory distress two days after bih.On examination he was observed to have a scaphoid abdomen and decreased breath sounds on the left side. He was managed by prompt Endotracheal intubation .After ET tube placement the maximal cardiac impulse shifted fuher to the right side. What should be the next step in management?
Answer is B (Remove tube and Reattempt intubation): The ideal next step is to confirm the position of ET tube and / or Remove the tube and reattempt intubation, if the tube is not in the trachea.As none of the options provided in the question can confirm the true position of the ET tube in the trachea the best course of action is to remove the tube and reattempt intubation. The patient in question is presenting with characteristic features of left sided diaphragmatic hernia. Incorrect placement of the tube into the esophagus (Esophageal intubation) will result in distension of stomach and bowel loops in the left hemithorax which would inturn shift the mediastinum and apical impulse to the right. The apical cardiac impulse in this patient has been observed to shift fuher to the right after attempted ET intubation. This raises doubt about the correct positioning of ET tube in the trachea and suggests the possibility of improper placement of the ET tube into the esophagus. The best next step in such a scenario is to confirm the position of ET tube. None of the options provided in the question however allow us to confirm the position of the ET tube in the trachea An X- ray chest cannot distinguish between tracheal and esophageal intubation and cannot confirm the position of the ET tube in the trachea. Hence option (A) can be excluded. A postero- anterior chest X-Ray (PA chest) can not confirm the position of tube in the trachea, as the oesophagus is situated immediately behind the trachea. A chest x-ray taken following intubation is done to confirm correct length of the tube rather than to find out whether it is sited in the trachea. This leaves us still in doubt regarding the correct position of the ET tube and when in doubt, the best course of action is to remove the tube and reattenzpt intubation. When in doubt take it out'. It is easy to wrongly intubate the esophagus. This must be recognized immediately. If the clinical state of the patient deteriorates after intubation or if there is any doubt about tube placement, the tube should be removed' - Lee
Confirm the position of endotracheal tube by chest X ray
Remove tube and reattempt intubation
Nasogastric tube inseion & decompress the bowel
Chest X ray to confirm diagnosis