846: IS TRANSTRACHEAL POCUS HELPFUL IN DETERMINING ENDOTRACHEAL TUBE POSITION? A RANDOMIZED CONTROL TRIAL

Abstract

Introduction: Endotracheal tube (ETT) malposition is associated with adverse events. Chest x-ray (CXR) is the gold standard modality for determining ETT position and depth in the trachea. However, Point-of-Care Ultrasound (POCUS) has emerged as a novel non-invasive alternative. We aimed to determine if an integrated protocol employing both transtracheal ultrasound and CXR for identifying ETT malposition in the trachea, compared to CXR alone, would result in fewer adverse events. Methods: We performed a single-center randomized control trial of intubated patients in a multidisciplinary intensive care unit at an academic hospital. Intubated patients were randomized into two arms: POCUS integrated or CXR alone daily ETT monitoring. In both arms, trained sonographers assessed for ETT position and related adverse events: migration into bronchus, herniation into vocal cords, balloon rupture, unplanned extubation, and aspiration pneumonia. In the POCUS integrated arm, the ICU rounding team was provided with the sonographer’s findings to aid in clinical decision making. A Pearson’s Chi-Squared test was used to compare the results between the two arms. Results: A total of 76 patients amounting to 187 ventilator days were randomized to receive either POCUS integrated (91 ventilator days) or CXR alone (96 ventilator days) daily ETT monitoring. The average patient age was 57.8 years +/- 17.0 years. Most patients were intubated for airway protection (46.1%) and hypoxic respiratory failure (40.8%). There were 10 adverse events recorded (7 aspiration pneumonias, 1 herniation through the vocal cords, 2 migration into a bronchus) out of 187 ventilator days. There was a trend toward lower adverse events in the POCUS integrated group compared to the CXR alone group (2.2% vs. 8.3%; p=0.062, respectively). Furthermore, the ETT depth was adjusted more frequently in the POCUS integrated group compared to the CXR alone group; however, this was not statistically significant (7.7% vs. 3.1%; p=0.165, respectively). Conclusions: Based on our data, the integrated protocol employing transtracheal ultrasound and CXR did not result in fewer adverse events than CXR alone. However, there was a trend toward less adverse events with the integrated protocol, and further investigations with larger sample sizes are needed.