Confirmation Of Endotracheal Tube Position Research Articles

Three-PointUltrasonography for Confirmation of Endotracheal Tube Position in Children (TRUCE Study).

To investigate the diagnostic accuracy of three-point ultrasonography for confirmation of endotracheal tube (ETT) position among children undergoing endotracheal intubation (ETI) with chest radiograph as reference standard. This prospective observational study was conducted from January 2021 through December 2021 (12 mo) in the pediatric emergency room (PER) and pediatric intensive care unit (PICU), Division of Pediatric Critical Care, Advanced Pediatrics Centre (APC), Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Children aged 3 mo to 12 y, undergoing ETI in PER or PICU were included. Three-point ultrasonography (suprasternal notch and bilateral anterior chest) was done following ETI for confirmation of correct ETT position. Chest radiograph was used as a reference standard. Interobserver agreement between two investigators (IG and SKA) (kappa statistic) was determined for three-point ultrasonography to confirm the correct ETT position. One hundred fifty-five children with median (IQR) age of 4.5 (1-7) y were enrolled; 60% (n = 94) were males. On neck ultrasound, bilaminar sign was present in 100% of children. On lung ultrasound, bilateral and unilateral pleural sliding were present in 97.4% and 2.6% children, respectively. Three-point ultrasonography identified the correct position of ETT in 97.4% children as compared to 83.2% on chest radiograph. Sensitivity of three-point ultrasonography to identify the correct position of ETT was 98%. The interobserver agreement between two examiners was 96.8% (kappa of 0.53, p = 0.000). Three-point ultrasonography is an effective, sensitive, safe, and reproducible bedside method for identification of correct placement of ETT in children admitted to PER and PICU.

Ultrasonography Imaging versus Waveform Capnography in Detecting Endotracheal Tube Placement during Intubation at a Tertiary Hospital.

There is continued research to find new faster, highly accurate, easily accessible, and portable methods of confirming endotracheal tube position during intubation. A newer modality for visualizing endotracheal tube location is transtracheal or transcricothyroid ultrasonography. The aim of this study was to see if ultrasound machine can also be routinely used for the confirmation of endotracheal tube position in operating theaters along with capnograph. The study was observational and prospective, conducted from January 2017 to July 2017. Study locations were at the Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center operating rooms. Sample size taken was 95. In the study, 11 patients had esophageal intubation out of the 95. The accuracy of both ultrasonography and capnography was found to be 96.84%. For ultrasonography, the sensitivity, specificity, along with positive predictive value and negative predictive value were 97.62%, 90.91%, 98.80%, and 83.33%, respectively, while that for capnography were found to be 96.43%, 100%, 100%, and 78.57%, respectively. The kappa value was calculated to be 0.749, which suggested the degree of agreement of result between the methods to be good. Compared to capnography, ultrasonography was found to be significantly faster for the confirmation of endotracheal tube location by 16.36 s (15.70-17.02) (P = 0.011). Both waveform capnography and ultrasonography were found to be accurate and reliable in confirming endotracheal tube location. The use of ultrasound during intubation can help confirm endotracheal tube location faster and also aid in precision when used along with capnography. Manual bag ventilations are not necessary when confirming endotracheal tube position by ultrasonography and thus may help in preventing aspiration of gastric contents into the lungs of the patient.

Novel technique for uninterrupted confirmation of endotracheal tube position for awake fiberoptic intubation

Oral Presentation, World Airway Management Meeting, 2019,13-16 November, Amsterdam, Netherland

Utility of ultrasound of upper airway for confirmation of endotracheal intubation and confirmation of the endotracheal tube position in the intensive care unit patients

Background: Endotracheal intubation in the intensive care unit (ICU) is an extremely high risk procedure. Rapid confirmation of endotracheal tube (ETT) placement and position to the correct depth is vitally important. Various methods are used to confirm placement of ETT. Capnography is the gold standard for confirmation of ETT placement in the trachea, but is not useful for ETT placement at the correct depth in the trachea. We conducted this study to evaluate the utility of airway ultrasonography for real time confirmation of ETT placement and also to confirm appropriate depth of the ETT. Methods: In this prospective, single-centre study, we included all adult patients intubated in the ICU. We obtained deferred consent from the Institutional Ethics Committee. We performed airway ultrasonography real time during intubation and detected ETT placement by loss of snow storm sign. Tracheal placement was also confirmed by capnography. We used saline filled cuff method to place ETT cuff depth at 3 rd and 4 rd tracheal ring and confirmed the appropriateness of the ETT depth on chest X-ray. We calculated the sensitivity and specificity of this technique. Results: We included 89 patients for the study. The ultrasound detection of the placement of the tube with the loss of snow storm sign was seen in 86 patients. The incidence of esophageal intubations was 2.0%. The overall sensitivity of airway ultrasound for confirmation of ETT placement was 96% (CI: 0.89–0.99) and specificity was 100%. The PPV was 100% (CI: 0.94–1.00). The accuracy for appropriateness of final position of ETT by airway ultrasound as compared to X-ray was found to be 96% (CI: 0.71–0.87). No complications were observed related to cuff inflation and deflation and to the use of airway ultrasound. Conclusions: Airway ultrasonography can be used for rapidly detecting ETT placement in the trachea as well as for determining appropriate depth insertion of the ETT with saline filled cuff technique.

A review of diagnostic accuracy and clinical impact from the focused use of perioperative ultrasound.

To perform a narrative review of the current trials examining the use of perioperative ultrasound to diagnose common issues related to the heart, lungs, stomach, and airway. A review of the current literature was conducted in June 2017 on all trials involving ultrasound, including both surface and transesophageal ultrasound, in the perioperative period. The search included the terms 'ultrasonography', 'perioperative care', 'point-of-care', and 'bedside'. Trials were limited to human subjects with no language or time restrictions being applied. The results were then collected and a narrative review was completed with the available information. In total 1,176 reports of original investigation or systematic reviews were collected and reviewed. Of those 1,176 reports and reviews, a total of 80 original articles met the inclusion criteria for this review. Topics were broadly defined based on common themes emerging from the literature including cardiac disease, lung pathology (pneumothorax, pleural effusion, pulmonary edema, and pulmonary consolidation), volume and contents of the stomach, confirmation of endotracheal tube position, confirmation of lung isolation, and the application of ultrasound for guiding cricothyroidotomy. Where possible, the sensitivity and specificity of the trials are presented. Few trials reported on patient outcomes, although several discussed provider outcomes such as a change in anesthesia practice. In addition, trials reporting outcomes, although few in number, were included. Perioperative point-of-care ultrasound is a useful method for the diagnosis of many important perioperative conditions. The impact of this diagnostic approach on patient outcomes however remains to be determined.

Relationship between Documented Confirmation of Endotracheal Tube Position and Mortality in the Emergency Department

Relationship between Documented Confirmation of Endotracheal Tube Position and Mortality in the Emergency Department

Endotracheal Tube Position Confirmation by the Bedside Ultrasound in Respiratory Intensive Care Unit Patients

Endotracheal Tube Position Confirmation by the Bedside Ultrasound in Respiratory Intensive Care Unit Patients

A Multifaceted Quality Improvement Program Improves Endotracheal Tube Confirmation Documentation in the Emergency Department

Confirmation of endotracheal tube (ETT) position is an essential part of emergency department (ED) airway care. The study team evaluated the effect of a multifaceted quality improvement initiative on improving confirmation documentation rates. Rates of documentation of appropriate methods of ETT position confirmation were better for patients undergoing ETT placement in the study site ED than for those arriving already intubated (103/127 [81.1%] vs 19/71 [26.8%]; relative risk [RR] = 3.03; 95% confidence interval [CI] = 2.04 to 4.49). Overall rates of documentation of appropriate methods of ETT position confirmation were higher after the intervention (557/758 [73.5%] vs 122/198 [61.6%]; RR = 1.19; 95% CI = 1.06 to 1.34), with a greater increase among the group presenting to the ED with an ETT already placed (116/259 [44.8%] vs 19/71 [26.8%]; RR = 1.67; 95% CI = 1.11 to 2.51) compared with those intubated in the study site ED (103/127 [81.1%] vs 441/499 [88.4%]; RR = 0.92; 95% CI = 0.8389 to 1.0039).

Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view

Aims:To assess the sensitivity and specificity of right subcostal ultrasound view to confirm correct endotracheal tube intubation (ETT).Materials and Methods:In this prospective study, apneic or paralyzed patients who had an indication of intubation were selected. Intubation and ventilation with bag were performed by the skilled third-year emergency medicine residents. The residents, following a brief training course of ultrasonography, interpreted the diaphragm motion, and identified either esophageal or tracheal intubation. The confirmation of ETT placement was done by the sonographer. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for tracheal versus esophageal intubation.Results:A total of 57 patients aged 59 ± 5 who underwent ETT insertion were studied. Thirty-four of them were male (60%). Ultrasound correctly identified 11 out of 12 esophageal intubations for a sensitivity of 92% (95% CI = 62-100), but misidentified one esophageal intubation as tracheal. Sonographers correctly identified 43 out of 45 (96%) tracheal intubations for a specificity of 96% (95% CI = 85-99), but misdiagnosed two tracheal intubations as esophageal.Conclusions:This study suggests that diaphragm motion in right subcostal ultrasound view is an effective adjunct to diagnose ETT place in patients undergoing intubation in emergency department.

376 Documentation of Endotracheal Tube Position Confirmation Among Different Emergency Department Providers

376 Documentation of Endotracheal Tube Position Confirmation Among Different Emergency Department Providers

Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from in-hospital cardiac arrest

ObjectivesTo determine the rate of appropriate documentation of endotracheal tube (ET) position confirmation in the American Heart Association's Get With the Guidelines-Resuscitation (GWTG-R) and to determine whether outcomes of patients who experience in-hospital cardiac arrest differ in relation to documentation rate. DesignAnalysis of data from the GWTG-R, a prospective observational registry of in-hospital cardiac arrest and resuscitation. SettingDatabase containing clinical information from the 507 hospitals participating in the GWTG-R. PatientsAdults resuscitated after in-hospital cardiac arrest. MeasurementsThe rate of appropriate documentation of ET position confirmation, defined as the use of capnography or an esophageal detector device (EDD); relationship between appropriate documentation of ET position confirmation and return of spontaneous circulation (ROSC) or survival to hospital discharge. Proportions with 95% CI are reported for prevalence data. Binary logistic regression was used to determine the relationship between appropriate documentation of ET position confirmation and outcome (ROSC, survival to hospital discharge). Adjusted and unadjusted odds ratios are reported. Main resultsOf the 176,054 patients entered into the GWTG-R database, 75,777 had an ET placed. For 13,263 (17.5%) of these patients, ET position confirmation was not documented in the chart. Auscultation alone was documented in 19,480 (25.7%) cases. Confirmation of ET position by capnography or EDD was documented in 43,034 (56.8%) cases. ROSC occurred in 39,063 (51.6%), and 13,474 (17.8%) survived to discharge. Patients whose ET position was confirmed by capnography or EDD were more likely to have ROSC (adjusted OR 1.229 [1.179, 1.282]) and to survive to hospital discharge (adjusted OR 1.093 [1.033, 1.157]). ConclusionDocumentation of ET position confirmation in patients who experience cardiac arrest is suboptimal. Appropriate documentation of ET position confirmation in the GWTG-R is associated with greater likelihood of ROSC and survival to hospital discharge.

Ultrasound Confirmation of Endotracheal Tube Position in Neonates

Background: The placement of the endotracheal tube (ETT) in neonates is a challenging procedure that currently requires timely confirmation of tip placement by radiographic imaging. Objective: We sought to determine if bedside ultrasound (US) could demonstrate ETT tip location in preterm and term newborns and offer a quick alternative method of ETT positioning. Methods: We conducted a prospective pilot study of 30 newborns admitted to the UC San Diego Medical Center who had their ETT placement confirmed by chest radiographs. After a radiograph, each infant had a US exam with a 13-MHz linear transducer on a portable US machine. To assist localization, gentle longitudinal movement of the ETT of less than 0.5 cm was performed. Measurements from the tip of the ETT tip to the carina were made on chest radiograph and midsagittal US images. Results: Study infants had a mean gestational age of 30.2 ± 4.9 (SD) weeks and mean birth weight of 1,595.2 ± 862 g. US images were taken a mean 2.9 ± 2.2 h after radiographs. Data from 2 infants were excluded for poor radiograph image quality and extreme outlier values. The ETT was visualized by US in all newborns examined. We observed a good correlation between ETT tip-to-carina distance on US and radiograph (r² = 0.68) with minimal bias. Each study took less than 5 min to obtain without any clinical deterioration. Conclusions: Bedside US can visualize the anatomic position of the ETT position in preterm and term infants but further validation is required before routine clinical implementation.

Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency Intubation

Aim of studyUnrecognized one-lung intubations (also known as main-stem intubation) can lead to hypoventilation, atelectasis, barotrauma, and even patient death. Many traditional methods can be employed to detect one-lung intubation; however, each of these methods has limitations and is not consistently reliable in emergency settings. This study aimed to assess the accuracy and timeliness of ultrasound to confirm proper endotracheal intubation. MethodsThis was a prospective, single-center, observational study conducted at the emergency department of a national university teaching hospital. Patients received emergency tracheal intubation because of respiratory failure or cardiac arrest. After intubation, bedside ultrasound was performed with a transducer placed on the chest bilaterally at the mid-axillary line, to identify lung sliding over the lungs bilaterally during ventilation. Chest radiography was used as the criterion standard for confirmation of endotracheal tube position. ResultsOne hundred and fifteen patients needing tracheal intubation were included, and nine (7.8%) had one-lung intubations. The overall accuracy of ultrasound to confirm proper endotracheal intubation was 88.7% (95% confidence interval (CI): 81.6–93.3%). The positive predictive value was 94.7% (95% CI: 87.1–97.9%) in the non-cardiac-arrest group and 100% (95% CI: 87.1–100.0%) in the cardiac-arrest group. The median operating time of ultrasound was 88s (interquartile range [IQR]: 55.0, 193.0), and of chest radiography was 1349s (IQR: 879.0, 2221.0) post intubation. ConclusionsIn this study, the positive predictive value of bilateral lung sliding in confirming proper endotracheal intubation was high, especially among patients with cardiac arrest. Considerable time advantage of ultrasound over chest radiography was demonstrated.

Analytic Review: Confirmation of Endotracheal Tube Position: A Narrative Review

Endotracheal tube (ETT) insertion is the primary method of definitive airway protection and control in critically ill patients. Detection of ETT malposition in a timely fashion is crucial in both elective and emergent intubation. In this review, we describe classic tests and highlight several new technologies that may assist the practitioner in determining ETT position within the esophago-tracheal complex, namely ultrasonographic and impedance-based methods. Strengths and weaknesses of particular methods are highlighted. Although many physical examination maneuvers have been described, reliance on the physical examination alone is insufficient for confirmation. Touted methods that appear failsafe, such as direct visualization of the ETT traversing the vocal cords have limitations, especially when dealing in the emergency setting accompanying a difficult to visualize airway. While carbon dioxide detection is an excellent confirmatory method, it is not infallible. Esophageal detection devices are useful as an alternative means of confirmation. New methods such as ultrasonic location of the ETT show promise but require further study. The clinician performing ETT insertion should have multiple confirmation methods that allow the practitioner to adapt to a variety of clinical situations, depending on local costs and availability. Finally, when the clinician still has uncertainty, or multiple tests give conflicting results, the availability of bronchoscopy at the bedside to visualize the carina through the ETT is useful.

Bedside Ultrasonography and Endotracheal Tube Placement: A Long Way to Go: In Reply

We thank Sundaram et al for their interest in our published study1; they raise several important points that deserve discussion. With regards to their first point, direct laryngoscopy (DL) is unequivocally the gold standard for confirming endotracheal tube (ETT) placement. DL is not always possible, and ETTs can slip out of place before being secured or move during transport.2 Colorimetric end-tidal carbon dioxide detection (CECD) remains the standard for secondary confirmation of ETT position in the trachea.3 We propose the use of both CECD and bedside ultrasonography (BUS), along with DL and clinical examination, to confirm ETT placement. …

9: Emergency Department Capnographic Confirmation of Endotracheal Tube Position in Out-of-Hospital Cardiac Arrest Patients

9: Emergency Department Capnographic Confirmation of Endotracheal Tube Position in Out-of-Hospital Cardiac Arrest Patients

Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement

Visualization of the vocal cords and end-tidal capnography are the usual standards in confirming endotracheal tube placement. Vocal cord visualization is, however, not always possible, and capnography is not 100% reliable and requires ventilation of the lungs to confirm placement. The goal of this study is to determine the accuracy of ultrasonography for detecting endotracheal tube placement into the trachea and esophagus in real time. This was a prospective, randomized, controlled study. Eligible patients were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, and esophageal disease. Thirty-three patients were enrolled. After induction of anesthesia and neuromuscular blockade, the anesthesiologist placed the endotracheal tube in the trachea and esophagus in random order with direct laryngoscopy. During the intubations, a high-frequency, linear transducer was placed transversely on the neck at the suprasternal notch. Two emergency physicians, blinded to the order and performance of the intubations, independently recorded the location of the endotracheal tube according to the real-time ultrasonographic image. A 2-by-2 table was used to calculate sensitivity and specificity of the emergency physicians' ability to detect placement of the endotracheal tube. For each physician, the sensitivity for identifying the first intubation as tracheal was 100% (95% confidence interval [CI] 77% to 100%) with a specificity of 100% (95% CI 82% to 100%). One endotracheal tube was unintentionally placed twice in the esophagus, but both tube placements were identified as esophageal by the emergency physicians. In this pilot study, 2 emergency physicians experienced in ultrasonography accurately detected placement of endotracheal tubes during intubation with ultrasonography in select patients in the controlled environment of the operating room. Future studies should examine the use of ultrasonography to visualize endotracheal tube placement in real time by emergency physicians with less ultrasonographic training; use of the technique in the emergency department on a wider range of patients, including patients with difficult airways; and assessment of the utility of ultrasonography in confirmation of endotracheal tube position in already intubated patients.

The Use of End-tidal Carbon Dioxide Monitoring to Confirm Endotracheal Tube Placement in Adult and Paediatric Intensive Care Units in Australia and New Zealand

The use of end-tidal carbon dioxide monitoring to assist in confirming endotracheal tube placement is currently not mandatory in intensive care units (ICUs) in Australia and New Zealand. Early detection of failed tracheal intubation is vital to optimize management and to prevent complications. Questionnaires were sent to the lead clinician/head of department of all 66 intensive care units approved for training purposes by the Joint Faculty of Intensive Care Medicine in Australia and New Zealand. The methods used to confirm correct endotracheal tube placement, the availability of end-tidal carbon dioxide monitoring and its role in confirming endotracheal tube placement in the intensive care unit were explored. Completed questionnaires were received from 61 of the 66 centres (92.4%). Wide variation in the method of confirmation of endotracheal tube position was demonstrated, with 23 (37.7%) of units using sub-optimal methods. Sixty (98.3%) of units had end-tidal carbon dioxide monitoring available. Thirty-eight (62%) units shared monitors between several beds; and 22 (36%) had one monitor per bed. End-tidal carbon dioxide monitoring was used routinely to confirm endotracheal tube placement in 42 (68.8%) units. Fifty-two respondents (83.3%) felt that end-tidal carbon dioxide monitoring was superior to other methods for confirming endotracheal tube placement in critically ill patients. Thirty-eight respondents (62.3%) thought that end-tidal carbon dioxide monitoring should be mandatory to confirm tracheal intubation in the intensive care unit. If it were available, 42 respondents (68.8%) would use end-tidal carbon dioxide monitoring for confirmation of every intubation. Mandatory end-tidal carbon dioxide confirmation of endotracheal tube placement was policy in 33 (54.1%) of the intensive care units.

Secondary confirmation of endotracheal tube position by ultrasound image

Secondary confirmation of endotracheal (ET) tube position by ultrasound image. Prospective, randomized study. A medical center-based tertiary pediatric intensive care unit. A total of 59 patients aged from newborn to 17 yrs old underwent ET tube insertion because of cardiopulmonary arrest or impending respiratory failure. Ultrasound imaging was performed immediately before and after the ET tube placement procedure. The most frequently used ultrasonic scanning window was the subxiphoid window at the mid-upper abdominal, just beneath the xiphoid process and the lower margin of liver. The sector angle was set as wide as possible (90 degrees) so that the bilateral diaphragm could be well scanned. Using the ultrasound imaging method, we successfully identified all of two esophageal intubations and eight incidents of initial ET tube misplacement, which had been positioned down to the right main bronchus. Finally, we successfully identified all 59 of the correct placements of ET tubes in the trachea. Ultrasound imaging of diaphragm motion is a useful, quick, noninvasive, portable, and direct anatomic method for assessment of ET tube position. We think it should be considered the method of choice for the secondary confirmation of the ET tube position.

T HE U SE OF E TOMIDATE FOR P REHOSPITAL R APID-SEQUENCE I NTUBATION

Prehospital hypoxia and hypotension increase morbidity and mortality in head-injured patients. Etomidate is a sedative agent with increasing use for emergent rapid-sequence intubation (RSI) because of its favorable hemodynamic profile. This prospective, observational study documents the authors' preliminary experience with etomidate as part of an aeromedical RSI protocol. Major trauma victims received etomidate 0.1 to 0.3 mg/kg intravenously (IV) before administration of a neuromuscular-blocking agent. After confirmation of endotracheal tube position, 1 to 2 mg midazolam IV was administered. The main outcome measure was systolic blood pressure (SBP) before and after the RSI procedure and the incidence of hypotension after RSI; individual patient plots of SBP versus time were also included for graphic analysis. An improvement in SBP after RSI with etomidate was observed (123 mm Hg to 136 mm Hg, p = 0.011) with a 9% incidence of hypotension, defined as a decrease in SBP to 90 mm Hg or less. Graphic analysis of individual SBP-time plots reveals hemodynamic stability, especially in patients with lower initial SBP values. These data suggest that the use of etomidate as part of a prehospital RSI protocol is associated with hemodynamic stability and a low incidence of hypotension.