Abstract
IntroductionRecent research has investigated the use of ultrasound (US) for confirming endotracheal tube (ETT) placement with varying techniques, accuracies, and challenges. Our objective was to evaluate the accuracy of a novel, simplified, four-step (4S) technique.MethodsWe conducted a blinded, randomized trial of the 4S technique utilizing an adult human cadaver model. ETT placement was randomized to tracheal or esophageal location. Three US experts and 45 emergency medicine residents (EMR) performed a total of 150 scans. The primary outcome was the overall sensitivity and specificity of both experts and EMRs to detect location of ETT placement. Secondary outcomes included a priori subgroup comparison of experts and EMRs for thin and obese cadavers, time to detection, and level of operator confidence.ResultsExperts had a sensitivity of 100% (95% CI = 72% to 100%) and specificity of 100% (95% CI = 77% to 100%) on thin, and a sensitivity of 93% (95% CI = 66% to 100%) and specificity of 100% (95% CI = 75% to 100%) on obese cadavers. EMRs had a sensitivity of 91% (95% CI = 69% to 98%) and of specificity 96% (95% CI = 76% to 100%) on thin, and a sensitivity of 100% (95% CI = 82% to 100%) specificity of 48% (95% CI = 27% to 69%) on obese cadavers. The overall mean time to detection was 17 seconds (95% CI = 13 seconds to 20 seconds, range: 2 to 63 seconds) for US experts and 29 seconds (95% CI = 25 seconds to 33 seconds; range: 6 to 120 seconds) for EMRs. There was a statistically significant decrease in the specificity of this technique on obese cadavers when comparing the EMRs and experts, as well as an increased overall time to detection among the EMRs.ConclusionThe simplified 4S technique was accurate and rapid for US experts. Among novices, the 4S technique was accurate in thin, but appears less accurate in obese cadavers. Further studies will determine optimal teaching time and accuracy in emergency department patients.
Highlights
Recent research has investigated the use of ultrasound (US) for confirming endotracheal tube (ETT) placement with varying techniques, accuracies, and challenges
emergency medicine residents (EMR) had a sensitivity of 91% and of specificity 96% on thin, and a sensitivity of 100% specificity of 48% on obese cadavers
The overall mean time to detection was 17 seconds for US experts and 29 seconds for EMRs
Summary
Recent research has investigated the use of ultrasound (US) for confirming endotracheal tube (ETT) placement with varying techniques, accuracies, and challenges. Rapid and reliable confirmation of endotracheal tube (ETT) placement during intubation is essential. The incidence of esophageal intubation during emergency conditions has been reported to be as high as 8-14%.1,2. Methods of confirmation include direct visualization of passage, chest and abdominal auscultation, esophageal detector devices, pulse oximetry, and end tidal capnography (both colorimetric and quantitative). Continuous end tidal CO2 has become the preferred method,[3] there are still significant risks of false positives with hypopharyngeal placement and false negatives during cardiac arrest.[4,5,6] continuous end tidal CO2 monitoring is not widely available in many emergency departments (EDs).[7]
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