Confirmation Of Endotracheal Tube Placement Research Articles

Endotracheal Tube Placement Confirmation with Bedside Ultrasonography in the Pediatric Intensive Care Unit: A Validation Study.

Critically ill patients who are intubated undergo multiple chest X-rays (CXRs) to determine endotracheal tube position; however, other modalities can save time, medical expenses, and radiation exposure. In this article, we evaluated the validity and interrater reliability of ultrasound to confirm endotracheal tube (ETT) position in patients. A prospective study was performed on intubated patients with cuffed ETTs. The accuracy of ultrasound to confirm correct ETT placement in 92 patients was 97.8%. Sensitivity, positive predictive value, and agreement of 97.7, 93.3, and 91.3% were found on comparing ultrasound to CXR findings. Ultrasound is feasible, reliable, and has good interrater reliability in assessing correct ETT position in children.

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Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.

The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies. We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods. We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed. Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively. Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

Utility of upper airway ultrasound for confirmation of endotracheal tube placement in the pediatric intensive care unit setting

Introduction: Confirmation of correct placement of the endotracheal tube (ETT) is as important as the procedure itself. Point-of-care ultrasound today is an indispensable modality in the intensive care unit (ICU) for augmenting the clinical assessment and guiding critical care procedures. In this study, we used point-of-care ultrasound to confirm ETT placement and compared the time taken to confirm the ETT placement by ultrasound and capnography (the gold standard of confirmatory ETT placement). Materials and Methods: The current study was a prospective study done in a tertiary care teaching hospital. Children between 1 month and 18 years of age were included in the study. Airway ultrasound was done during the intubation procedure by placing the probe transversely over the suprasternal notch, and the confirmation of placement of the tube in the trachea was done by visualizing the absence of double trachea sign, and later confirmed by capnography. The average time taken for confirmation by ultrasound and capnography was determined. Results: A total of 127 intubations were included. The average time taken for confirmation of placement of the ETT by airway ultrasound from the time of insertion of the laryngoscope blade was 26.8 ± 5.7 s, whereas by capnography, it was 35.5 ± 5.8 s. The study showed that airway ultrasound has a high sensitivity of 98.2% to detect tracheal intubation and specificity of 100% to detect esophageal intubation when compared to capnography. Conclusion: Airway ultrasound can serve as a novel method of confirming the ETT placement in the pediatric ICU with comparable sensitivity, specificity with the added advantage of a significantly faster time of confirmation with respect to capnography.

Focused airway ultrasound: an armamentarium in future airway management

Point-of-care ultrasound (POCUS) has gained the upper hand for being simple, non-invasive and portable. Traditional beliefs that ultrasound is futile in the imaging of air-filled structures has been refuted. Upper airway ultrasound is applicable to patients with distorted anatomy, not easily discernable by traditional methods, besides serving as a useful adjunct peri-intubation; as a pre-intubation screening tool for difficult laryngoscopy, selection of endotracheal tube (ETT) size and confirmation of ETT placement and depth, and to detect laryngeal mask airway (LMA) malrotation. Airway ultrasound also assists in procedural guidance for percutaneous cricothyroidotomy, percutaneous dilatational tracheostomy (PDT) and airway nerve blocks by improving success rate with fewer attempts and safety. In the critical care unit, sonographic parameters of the airway provide means to predict post extubation stridor hence successful extubation, in addition to identifying upper airway pathologies. The feasibility of focused airway ultrasound also lies in its shallow learning curve and the relative ease of mastering the skill with appropriate training. The integration of upper airway ultrasound into POCUS examination may be a prelude to a bigger picture in future airway management. Increasing awareness of the practicality of this tool, availability in critical areas and improving technological advancements will encourage more usage resulting in its incorporation into routine clinical practice.

Diagnostic Accuracy of Ultrasound for Confirmation of Endotracheal Tube Placement.

Diagnostic Accuracy of Ultrasound for Confirmation of Endotracheal Tube Placement.

Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department.

The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

Association Between Hospital Recognition for Resuscitation Guideline Adherence and Rates of Survival for In-Hospital Cardiac Arrest.

Background Hospitals participating in the national Get With The Guidelines-Resuscitation registry receive an award for high rates of adherence to quality metrics for in-hospital cardiac arrest. We sought to evaluate whether awards based on these quality metrics can be considered a proxy for performance on cardiac arrest survival. Methods and Results Among 195 hospitals with continuous participation in Get With The Guidelines-Resuscitation between 2012 and 2015, we identified 78 that received an award (Gold or Silver) for ≥85% compliance for all 4 metrics for in-hospital cardiac arrest-time to chest compressions, ≤1 minute; time to defibrillation, ≤2 minutes; device confirmation of endotracheal tube placement; and a monitored/witnessed arrest-for at least 12 consecutive months during 2014 to 2015. Award hospitals had higher cardiac arrest volumes than nonaward hospitals but otherwise had similar site characteristics. During 2014 to 2015, award hospitals had higher rates of return of spontaneous circulation for in-hospital cardiac arrest than nonaward hospitals (median [interquartile range], 71% [64%-77%] versus 66% [59%-74%]; Spearman ρ, 0.19; P=0.009). However, rates of risk-standardized survival to discharge at award hospitals (median, 25% [interquartile range, 22%-30%]) were similar to nonaward hospitals (median, 24% [interquartile range, 12%-27%]; Spearman ρ, 0.13; P=0.06). Among hospitals in the best tertile for survival to discharge in 2014 to 2015, 55.4% (36/65) did not receive an award, with poor discrimination of high-performing hospitals by award status (C statistic, 0.53). Similarly, there was only a weak association between hospitals' award status in 2014 to 2015 and their rates of survival to discharge in the preceding 2-year period (Spearman ρ, 0.16; P=0.03). Conclusions The current recognition mechanism within a national registry for in-hospital cardiac arrest captures hospital performance on return of spontaneous circulation but is not well correlated with survival to discharge. This suggests that current awards for resuscitation quality may not adequately capture hospital performance on overall survival-the outcome of greatest interest to patients.

Waveform capnography in a South African prehospital service: Knowledge assessment of paramedics.

BackgroundWaveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment.MethodsA cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants’ knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography.ResultsSeventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking.ConclusionParamedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent.

Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound.

Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation. A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience. During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location. Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.

Real-time Tracheal Ultrasound for the Confirmation of Endotracheal Intubations in the Intensive Care Unit: An Observational Study.

Current methods to confirm endotracheal tube (ETT) placement have varying degrees of effectiveness and time to completion. We aimed to study the accuracy of real-time tracheal ultrasound (US) to confirm ETT placement in the intensive care unit (ICU) setting. This work was a prospective study completed at 2 academic tertiary care centers. Patients in the adult ICU requiring emergent intubation were enrolled in the trial. During the intubation process, a US team performed a tracheal US examination to determine, in real time, whether the ETT was placed into the trachea or the esophagus. A total of 75 patients were enrolled in the study and were available for analysis. There were 12 (16%) esophageal intubations and 63 (84%) tracheal intubations. One hundred percent of the tracheal intubations and 83% of the esophageal intubations were correctly identified. The positive and negative predictive values of US to detect an esophageal intubation were 100% and 97%, respectively. Tracheal US can be highly accurate in identifying the location of the ETT, in real time, in ICU patients undergoing emergent intubation. Although our study shows a great potential of real-time US use during emergent intubations, larger studies would be needed to further evaluate the accuracy of this technique.

Abstract 3 - Feasibility of Obtaining In-Flight Evaluation of Endotracheal Tube Placement with Ultrasound during Helicopter Transport

Objective: Ultrasound evaluation of the trachea for confirmation of endotracheal tube placement in combination with evaluation of the bilateral lung apices for lung sliding have previously been evaluated in the emergency and critical care settings. A recent meta-analysis found pooled sensitivity of 93% and specificity 97% for the detection of esophageal intubation. 1 Chou E.H. Dickman E. Tsou P.Y. et al. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation. 2015; 90: 97-103 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Our objective was to demonstrate feasibility of obtaining these ultrasound images during flight.

Ultrasonography for Endotracheal Tube Placement Confirmation in an Emergency Setting - A Prospective Study in a Teritiary Hospital

Background: Ultrasonography, clinical methods and capnography are used to confirm the proper placement of endotracheal tube. Ultrasonography was thought to have high sensitivity and specificity and took less when compared with other two methods.&#x0D; Aims: To compare ultrasonography with the traditional clinical methods and the gold standard quantitative waveform capnography in confirming the proper placement of endotracheal tube.&#x0D; Materials and Methods: We carried out a prospective cohort study on 120 patients who were indicated for intubation in an emergency department of a tertiary care hospital, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana State, India. The study was carried out from June 2017 to December 2017. The confirmation of endotracheal tube placement was identified by three methods, ultrasonography, quantitative waveform capnography (end-tidal carbon dioxide) and traditional clinical method. The parameters recorded by three methods were confirmation of tube placement and time taken for tube placement.&#x0D; Results: Out of the 120 intubation attempts, six (5 %) had esophageal intubations. Ultrasonography produced a sensitivity and specificity of diagnosis of 98.63% and 100%, respectively, which was statistically comparable with the other two methods. When the time taken to confirm tube placement was compared, it was found that ultrasonography took significantly less time. The time taken by ultrasonography, waveform capnography and clinical methods was 8.13 ± 1.27, 17.86 ± 2.34 and 20.13 ± 2.72 seconds respectively.&#x0D; Conclusion: The endotracheal tube placement was confirmed by ultrasonography with comparable sensitivity and specificity to other two methods i.e. quantitative waveform capnography and clinical methods and it took less time.

Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study

ObjectivesConfirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber-optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time-consuming, and not always practical. Inexpensive endoscopic USB-cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB-camera. MethodsThis study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB-endoscopy. We have prepared a randomized intubation list (n=96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB-endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2cm wide ostium on the proximal trachea. ResultsIn this study, all intubations (n=96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB-camera. Both the sensitivity and specificity of TUS and USB-endoscopy for the CoETP were 100.0%. ConclusionThe perfect accuracy of TUS and USB-endoscopy, have placed those techniques in a unique position as an alternative in resource-poor situations.

Three-window ultrasonography confirmation of endotracheal tube placement

Background: Establishing a definitive airway is often an initial step in the management of critically ill patients in the emergency department (ED). Currently, there is no universally accepted gold standard for airway confirmation. Recent literature has shown that point-of-care ultrasound (POCUS) may be helpful in confirming the correct endotracheal tube (ETT) placement. Objective: The objective of this study is to evaluate the accuracy of a comprehensive three-window POCUS assessment to confirm correct ETT placement. Methods: This was a prospective, single-center, observational study using a convenience sample of patients in the ED and Medical Intensive Care Unit. After presumed successful ETT intubation, three sonographic windows were obtained, which included the trachea, bilateral lung sliding, and diaphragm movement. Results: We enrolled a total of 140 patients. There were no esophageal intubations. The three-window POCUS method correctly identified 132 of 137 ETTs placed in the trachea with 96.4% sensitivity (95% confidence interval [CI] 91.7%–98.8%) and 33.3% specificity (95% CI 0.8%–90.6%). Only one of the three mainstem intubations was identified using POCUS. Ultrasound assessment was completed on average 25 min quicker than the usual confirmatory plain film radiography (95% CI 6.2–43.9 min, P = 0.005). Conclusions: The three-window POCUS assessment is a rapid and potentially reliable method to identify ETT intubation, but may not be reliable at confirming mainstem intubation.

Verification of Endotracheal Intubation with Ultrasonography in Emergency Medicine Clinic

Introduction and Aim: Endotracheal intubation (EI) is vital in emergency medicine where airway management is critical. In literature haven't got any gold standard method for endotracheal tube (ET) confirmation. Aim of our study is to compare sensitivity and specificity of ultrasonography (USG) that has become widespread in emergency medicine, in confirmation of ET with other methods. Materials and Methods: This study is a clinical observational prospective single-centered and conducted at Emergency Department of A°zmir Bozyaka Training and Research Hospital in September – November 2014. All the patient above 18 years old who had been intubated because of medical indications and cardiac arrest are included. End-tidal waveform capnograph and oscultation were used. We used Ultrasonography (USG) just after incubation for confirmation of tube placement. During ventilation, both hemithorax and epigastric area were auscultated. Simultaneously, we used USG for lung sliding bilaterally. After six ventilations, we recorded value of partial pressure of carbon dioxide (pCO2) on capnograph and whether waveform was present, or not. Results: 37 patients were included to the study. 19 (51.4%) were men. 21 (56.8%) of the patient were intubated due to cardiac arrest, 2 (5.4%) of them due to low Glasgow coma scale (GCS), 12 (32.4%) of them too difficult intubation, 1 (2.7%) of them due to low partial pressure of oxygen (pO2), 1 (2.7%) of them to change ET. Sensitivity of USG for confirmation of tube placement is 100% (CI 95%; 40.23-100%), specificity is 96.97% (95%CI; 84.18-99.49%), positive predictive value (PPV) 80% (CI 95%; 28.81-96.70%), negative predictive value (NPV) 100% (CI 95%; 89.01-100%). Kappa value of USG is 0,87. Conclusion: USG is being largely used in emergency departments and shows high sensitivity and specificity to confirm ET placement. USG can be used to confirm endotracheal tube placement; so, complications of esophageal intubation can be avoided.

Endotracheal tube placement confirmation: 100% sensitivity and specificity with sustained four-phase capnographic waveforms in a cadaveric experimental model

BackgroundWaveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. MethodsWe conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO2) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. Results106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO2 values ranging 2–113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98–1.00) and 100% specificity (PPV 1.0, 95%CI 0.93–1.00). ConclusionThough current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.

Optimization of Ultrasound Transducer Positioning for Endotracheal Tube Placement Confirmation in Cadaveric Model

Sonography has been suggested as a possible means of endotracheal tube (ETT) placement confirmation. However, optimum ultrasound transducer placement has not been established. Using a cadaveric model, ETT placement by the sonographic appearance at the thyroid cartilage, cricoid cartilage, and suprasternal notch in the upper airway was assessed to determine which ultrasound transducer placement offered the most optimal images for ETT confirmation in the airway. One provider intubated 5 cadavers, with the ultrasound transducer at each of the 3 levels, for a total of 30 intubations per specimen, while 2 providers assigned a visual score of 1 (subtle), 2 (clear), or 3 (pronounced) to each sonogram of the ETT in the airway. At the level of the thyroid cartilage, tracheal intubation was detected at a rate of 40%, with a median visualization scale of 1 (subtle movement). At the level of the cricoid cartilage, the visualization scale improved to a median of 2 (clear movement), with a 70% intubation detection rate. At the level of the suprasternal notch, 100% of the tracheal intubations were visualized on sonography, with a median score of 3 (pronounced movement). In comparing sonographic detection of ETT placement at 3 levels of the upper airway in a cadaveric model, our results clearly indicate that visualization was superior at the level of the suprasternal notch, with 100% of intubations detected with the best visualization scores.

Screening Characteristics of Bedside Ultrasonography in Confirming Endotracheal Tube Placement; a Diagnostic Accuracy Study.

Confirmation of proper endotracheal tube placement is one of the most important and lifesaving issues of tracheal intubation. The present study was aimed to evaluate the accuracy of tracheal ultrasonography by emergency residents in this regard. This was a prospective, cross sectional study for evaluating the diagnostic accuracy of ultrasonography in endotracheal tube placement confirmation compared to a combination of 4 clinical confirmation methods of chest and epigastric auscultation, direct laryngoscopy, aspiration of the tube, and pulse oximetry (as reference test). 150 patients with the mean age of 58.52 ± 1.73 years were included (56.6% male). Sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio of tracheal ultrasonography in endotracheal tube confirmation were 96 (95% CI: 92-99), 88 (95% CI: 62-97), 98 (95% CI: 94-99), 78 (95% CI: 53-93), 64 (95% CI: 16-255), and 0.2 (95% CI: 0.1-0.6), respectively. The present study showed that tracheal ultrasonography by trained emergency medicine residents had excellent sensitivity (>90%) and good specificity (80-90) for confirming endotracheal tube placement. Therefore, it seems that ultrasonography is a proper screening tool in determining endotracheal tube placement.

End-tidal capnography and upper airway ultrasonography in the rapid confirmation of endotracheal tube placement in patients requiring intubation for general anaesthesia.

Background and Aims:Confirmation of correct endotracheal tube placement is essential immediately after intubation for general anaesthesia. In this study, we have compared upper airway ultrasonography (USG) with reference to capnography for rapid confirmation of endotracheal tube placement after general anaesthesia.Methods:A prospective, single centre, observational study was conducted on 100 patients requiring tracheal intubation for general anaesthesia. Both capnography and upper airway USG were performed immediately after intubation to confirm the endotracheal tube (ETT) placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. Agreement between the methods and time required to determine ETT placement by the two methods were assessed with kappa statistics and Student's t-test.Results:Upper airway USG detected all five cases of oesophageal intubation, but could not detect five patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.84% (95% confidence interval [CI]: 94.25%–96.84%), specificity of 100% (95% CI: 50.6%–100%), positive predictive value of 100% (95% CI: 97.3%–100%) and negative predictive value of 62.5% (95% CI: 31.6%–62.5%). Kappa value was found to be 0.76, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 8.989 ± 1.043 s vs. 12.0 ± 1.318 s for upper airway USG (P < 0.001).Conclusion:Both capnography and upper airway USG may be used as primary procedures for the confirmation of ETT placement.