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Suboptimal positioning of endotracheal tubes (ETs) is often identified on routine chest radiographs prompting adjustment. The accuracy of ET adjustments based on tube measurement markings at the incisors has not been reported.We performed a 1-year prospective observational study of all surgical intensive care unit patients requiring repositioning of their ET based on chest x-ray (CXR) study. The ET was repositioned by a respiratory therapist using tube markings at the incisors, and follow-up CXR images were obtained within 2 hours. ET tube locations were compared with the planned intervention. Mean, median, interquartile range (IQR) and χ2 results are reported.Fifty-five patients met inclusion criteria and had a complete set of data (80% male). ET advancement was the most commonly required intervention (80%). For advancement, the median starting position was 7.10 cm (IQR, 2.20 cm) from the carina, with a median planned advancement of 2.00 cm. The actual advancement was a median of 1.15 cm, achieving 57.5% of the goal. Patients requiring ET withdrawal were more likely female (8 of 11, p < 0.001). For the withdrawal group, the median starting position was 0.70 cm (IQR, 1.05 cm) from the carina with a planned median withdrawal of 2.00 cm (IQR, 0.75 cm). The actual withdrawal was a median of 1.00 cm, achieving 50.0% of the goal. Overall, the mean difference between the planned and actual intervention was 1.55 cm (95% confidence interval, 1.16–1.95 cm) differing by a mean of 40% from the planned intervention (95% confidence interval, 29.0–51.0%). There was no correlation between the original location or the planned intervention and the accuracy of the intervention. In three cases, the ET moved opposite of the planned intervention.ET repositioning based on measurement at the incisors is inaccurate and the magnitude of the intervention does not correlate with the degree of error. Repositioning of ETs based on measurements at the incisors should be abandoned, or follow-up CXR images should be obtained.Therapeutic study, level III.