39 Ability of Critical Care Medics to Confirm Endotracheal Tube Placement by Ultrasonography: A Simulation Study

Abstract

The 2015 ACLS guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement of the advanced airway. While this method is routinely employed in the emergency department, it has yet to gain wide acceptance in the out-of-hospital setting where it has the potential for greater impact. There are several barriers to increasing the use of ultrasound for advanced airway confirmation in the out-of-hospital setting. Two of the most obvious are the lack of available training opportunities and paucity of in-vivo cases to attempt this technique. We proposed a simulation-based approach to training medics in the use ultrasound for confirmation of ETT location and then tested participants using simulated cases with common associated pathology. Critical care medics who routinely perform intubations in the out-of-hospital setting were self-selected to participate in this training. Using a lecture format, they were taught the procedure to assess ETT placement with ultrasound and introduced to common pathologies. Then, they participated in a hands-on session to demonstrate normal anatomy and gain haptic ultrasound skills. Immediately following training, they were tested with five simulated case scenarios that demonstrated the following: two normal endotracheal intubations, esophageal intubation, right main stem intubation, and pneumothorax. Their accuracy and length of time to respond were measured, and a survey was used to assess applicability to the practice environment. 10 critical care medics completed the training session. Overall, there were 20 normal intubations and 30 pathologic cases presented. The results showed that 17/20 (85%) of the normal endotracheal, 8/10 (80%) of the esophageal intubations, 10/10 (100%) of the pneumothoraces, and 9/10 (90%) of the right main stem cases were identified correctly. The average time to diagnosis for each case is as follows: 18.3s for normal, 28.9s for esophageal, 19.5s for pneumothorax, and 22.6s for right main stem. All 10 medics “agreed” or “strongly agreed” that this simulation was useful for their practice, that they would use ultrasound to confirm ETT placement, and that simulation provided a realistic view of potential pathology encountered during ETT placement. The use of ultrasound to confirm ETT tube placement can be effectively taught to critical care medics using a short simulation-based training session. We found that during the testing phase, the medics became increasingly comfortable with interpreting the images as they progressed. It may be feasible to increase diagnostic accuracy with longer training sessions. Further studies on implementation into patient care scenarios are needed, especially if this is to become a commonly practiced approach to advanced airway confirmation under ACLS protocols.