Correct Endotracheal Tube Placement Research Articles

Confirmatory methods for endotracheal tube placement in out-of-hospital settings: A systematic review of the literature

BackgroundConfirming proper placement of an endotracheal tube (ETT) is important, as accidental misplacements may occur and lead to critical injuries, potentially leading to adverse outcomes. Multiple methods are available for determining the correct ETT placement in prehospital care. ObjectiveTo assess the accuracy and reliability of the different methods used to confirm endotracheal intubation in prehospital settings. MethodsA comprehensive literature search was performed in the MEDLINE, EMBASE, Scopus, and Web of Science databases for studies that were published between 1-June-1992 and 12-June-2022 using a combination of predetermined search terms. Studies that met the inclusion criteria were included and assessed for risk of bias using “Risk of Bias in Non-randomized Studies of Intervention” tool. ResultsOf the 1016 identified studies, nine met the inclusion criteria. Capnography and point-of-care ultrasound showed high sensitivity and specificity rates when applied to confirm ETT placement in prehospital care. Other methods including capnometry, colorimetric detectors, ODDs, and auscultation showed varied sensitivity and specificity. Patient comorbidities and device failure contributed to decreased accuracy rates in prehospital care. Capnography was less reliable in distinguishing between endotracheal intubation and right main stem intubation, which is known as a complication in out-of-hospital endotracheal intubation. Point-of-care ultrasound was more accurate and reliable in detecting oesophageal and endobronchial misplacements. ETCO2 monitors, i.e., capnometry and colorimetric detectors, were less reliable in patients with low perfusion states. ConclusionThis systematic review showed that there is no single method with 100% accuracy in confirming the correct ETT placement and detecting the occurrence of accidental oesophageal or endobronchial misplacements in prehospital care. Further studies with a larger sample size are needed to assess the accuracy of multiple confirmatory methods in prehospital settings.

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.

843: VIDEO LARYNGOSCOPY AND TEAM DYNAMICS DURING INTUBATION

Introduction: Intubation in the pediatric intensive care unit (PICU) involves teamwork between a proceduralist and team leader. Improved team dynamics may minimize harm to patients during this high-risk procedure. Video laryngoscopy (VL) allows multiple team members to view the glottic anatomy. Although VL use has increased, little is known about its influence on team dynamics. Our aim was to compare cognitive load, team member stress, and provision of feedback during VL versus direct laryngoscopy (DL) intubations. Methods: We prospectively studied intubations performed by the critical care team for children < 18 years old in an academic PICU from November 2021 to May 2022. Proceduralists and team leaders completed brief surveys after each intubation. We defined cognitive load using the validated Paas scale (range: 0-9) and the NASA Task Load Index (NASA-TLX, range: 0-100 on each of six domains). Team members were also queried regarding stress levels, perceptions of feedback, and confidence in endotracheal tube placement. Chi squared analysis was used to compare DL and VL. Results: Among 45 intubations during the study period, 41 surveys were completed by the proceduralist and 39 surveys were completed by the team leader. When measured using the Paas scale, cognitive load did not differ between VL and DL for the proceduralist or the team leader (P>0.05). When measured using NASA-TLX, cognitive load only differed for the proceduralist in 2 domains: increased effort (62.7 with VL vs. 49.4 with DL, P=0.017) and reduced performance (41.9 with VL vs. 17.4 with DL, P=0.044). Stress levels did not differ between VL and DL (P>0.05). The proceduralist received feedback more often with VL than DL (100% vs. 68%, p=0.005), however the team lead did not perceive a difference in ease of giving feedback with VL versus DL (P>0.05). The team leader had increased confidence in correct endotracheal tube placement using VL versus DL (3 vs. 2.84, p = 0.04). Conclusions: Although VL allows for a shared mental model during intubation by projecting glottic anatomy onto a screen, its use does not reduce team stress or cognitive load. Furthermore, the proceduralist finds VL to require more effort and decrease performance compared to DL. This may be due to less familiarity with VL or use of VL in more clinically stressful situations.

Capnography: Principles and application in critical care medicine

Capnography has become an essential monitoring tool in perioperative and critical care setting. It helps monitor dynamic physiological processes more precisely and promptly, compared to other monitoring modalities. Methods to measure and display carbon dioxide concentrations in respired gases include infrared spectrography, mass spectrography, Raman spectrography, photoacoustic analysers or colorimetry. It is used to confirm correct endotracheal tube placement, ensure effective and consistent chest compression, detect return of spontaneous circulation and diagnose alterations in haemodynamics and ventilation of critically ill patient. It helps to optimise fluid resuscitation and monitor shock progression by providing insight into adequacy of tissue perfusion. Thus, a detailed study and interpretation of capnographic waveform is essential.

A study of BlockBuster laryngeal mask airway versus Fastrach/Intubating laryngeal mask airway as a conduit for blind oro-tracheal intubation: A prospective randomized controlled study

A Laryngeal Mask Airway (LMA) has two parts, a simple breathing tube and a mask. The mask at the laryngeal end of the tube aligns against the glottis and provides better channel of ventilation than the face mask. There have been modifications in the basic design of the LMA to incorporate gastric drainage channel and some devices are also equipped with a channel for intubation to secure airway by guiding endotracheal tube (ETT) through it. In this study we evaluated the performance of two LMA devices that can aid in rescue ventilation and are also equipped with a channel for intubation namely the BlockBuster LMA(2012) and the Fastrach/ Intubating LMA(1997) for blind oro-tracheal intubation in terms of First attempt success rate and Over-all success rate of intubation. A hundred consenting patients of age group 18-60 years and ASA status I or II, were randomly allocated into two groups Group BB (BlockBuster LMA) and Group FT (Fastrach LMA) with 50 patients each. Standard anesthesia technique was used for both groups. After insertion of airway device, cuff was inflated and ventilation was attempted (maximum 2 attempts). Once ventilation was achieved, ETT of appropriate size was inserted through LMA (maximum 2 attempts). The correct placement of ETT was confirmed by capnography. Data was collected for number of attempts of tracheal intubation, time taken for intubation and complications. First attempt success rate of intubation was more in Blockbuster LMA than Fastrach LMA. Over-all success rate of Intubation was 100% for both devices. Time taken for intubation and incidence of post-operative sore throat was less in BlockBuster LMA than Fastrach LMA(p-value&amp;#60;0.05). Blockbuster LMA is better conduit for oro-tracheal intubation than Fastrach LMA in terms of higher first attempt success rate, lesser time taken for intubation and lesser post-operative complications.

Pediatric Advanced Life Support in a Neonatal Context.

Pediatric Advanced Life Support in a Neonatal Context.

Diagnostic Accuracy of Suprasternal Versus Subxiphoid Ultrasonography for Endotracheal Intubation.

BackgroundAirway management is an important skill for emergency physicians, and confirmation of correct endotracheal tube (ETT) placement is a crucial component of airway management.ObjectivesDue to the occurrence of incorrect ETT positioning in emergency departments, the present study aimed to compare the diagnostic sensitivity of ultrasound using suprasternal and subxiphoid methods for confirming the correct placement of ETT compared to capnography.MethodsThis cross-sectional study was conducted by examining patients requiring intubation. Ultrasound was performed by two independent emergency medical assistants using two suprasternal and subxiphoid methods to confirm correct ETT placement; the results were then interpreted. To observe the tube passage through the vocal cords, capnography and lung auscultation were applied as the gold standards, and the results of two ultrasound methods were compared.ResultsA total of 66 patients, who were intubated in the emergency department, participated in this study. The positive and negative predictive values, sensitivity, and specificity of supernatural ultrasound were 96.72%, 80%, 98.33%, and 66.67%, respectively. Also, positive and negative predictive values, sensitivity, and specificity of subxiphoid ultrasound were 97.95%, 29.41%, 80%, and 83.33%, respectively. The diagnostic odds ratios of suprasternal and subxiphoid ultrasounds were 1.026 and 1.024 compared to capnography, respectively.ConclusionsUltrasonography using the suprasternal method was feasible. Considering the high sensitivity and specificity of this method in confirming correct ETT placement, it produced reliable results. Overall, this modality can be used as one of the main methods to verify correct ETT placement in emergency departments.

Development and internal validation of an equation using anthropometric measures to predict correct endotracheal tube insertion depth.

PurposeTo develop, internally validate, and assess the utility of implementing a regression model for determining endotracheal tube (ETT) insertion depth.Research methodsWe recorded height, weight, age, sex, ETT internal diameter (ID), lip marking, and tracheal position from the electronic record from a random subset of 2,000 intubated subjects obtained from 1 January 2009 to 5 May 2012. A multivariable linear regression model was constructed and validated by a nonparametric bootstrapping technique using unrestricted random sampling methods. A prospective pilot of subjects admitted to the pediatric intensive care unit requiring invasive mechanical ventilatory support was conducted from 7 January 2019 to 31 May 2019. Those with spinal and/or skeletal malformations, without a post-intubation chest-x-ray (CXR) order, or whose CXR quality impaired visualizing the carina and ETT tip, were excluded. The validated regression equation determined insertion depth. CXR following intubation determined ETT position. Demographic data were summarized. Two-tailed, one-sample binomial test of proportions assessed differences in the proportion of correct position by the equation.Main findingsFour hundred and seventy-seven subjects included in model construction yielded 10,000 independent samples for internal validation; 55% were female, and the mean age (SD) was 47 (63) months. Bias between bootstrap coefficients and refined model estimates were negligible (P < 0.01). Eleven subjects in the pilot were female (64%), mean age (SD) of 36.7 (38) months. Four protocol violations (36.4%) resulted in malposition. Subsequent repositioning per protocol resulted in 100% correct positioning (P = 0.01).ConclusionThe regression equation [0.8636 * (Ht. 0.6223)] facilitated correct ETT placement. A larger, diverse sample is required for external model validation.

Verification of Endotracheal Tube Position by Emergency Nurses Using Ultrasound: A Repeated Measures Cadaver Study

IntroductionEndotracheal intubation is a lifesaving procedure frequently performed in emergency departments. It is associated with some potential risks. Rapid and reliable confirmation of endotracheal tube placement during intubation is critical. Nurses play an important role in the care of patients in various settings. Ultrasound can be performed and interpreted not only by physicians but also by nurses. The aim of this study was to evaluate how well nurses without previous ultrasound experience can determine both esophageal and tracheal localization of endotracheal tubes in cadavers after a short ultrasound training. MethodsThis was a repeated measures study with an educational intervention and no control/contemporaneous comparison group. The study was performed to evaluate the ability of emergency nurses to confirm correct endotracheal tube placement and identify esophageal intubations. A total of 7 emergency nurses were given theoretical education and hands-on training about ultrasound. They diagnosed tracheal or esophageal intubation using ultrasound. ResultsFour cadavers were used 8 times each for the study. A total of 32 intubation procedures were evaluated with ultrasound by each nurse. In the analysis based on 224 responses, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and overall accuracy of ultrasound applied by nurses to detect tracheal intubation were 95.61% (90.06%-98.56%), 97.27% (92.24%-99.43%), 35.06 (11.48-107.10), 0.05 (0.02-0.11), and 96.43% (93.08%-98.45%), respectively. The mean time to evaluate the tube location by ultrasound was 6.57 seconds. DiscussionThe results support that ultrasound can be performed by nurses for the confirmation for esophageal and tracheal intubations quickly and accurately.

Comparison of ultrasonography, clinical method and capnography for detecting correct endotracheal tube placement- A prospective, observational study.

In emergency airway management, unstable haemodynamics of the patients calls for the early need to detect correct endotracheal tube (ETT) placement. Ultrasonography has an advantage of being readily available along with being non-invasive and providing real time images. We aimed to study the usefulness of tracheal ultrasonography and use it as a tool to assess correct tracheal intubation in patients in the intensive care unit. This was a hospital-based observational study. The study included 92 patients who needed and were taken up for endotracheal intubation. Tube placement was confirmed simultaneously by three different observers with their respective method, i.e., ultrasonography, clinical method and capnography. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography against capnography were 100% each with P value of 1. However, for clinical method against capnography, the sensitivity was 96.5%, specificity 28.6%, PPV 94.3% and NPV 40% with P value of 0.727. Mean time taken to detect correct placement of the ETT by ultrasonography, capnography and clinical method was 4.93 s, 15.39s and 17.80s, respectively. Out of 92 intubations, 85 were tracheal and 7 were oesophageal. All intubations were detected accurately with ultrasonography and capnography, ultrasonography being faster. Clinical method correctly detected 82 out of 85 tracheal intubations and 2 out of 7 oesophageal intubations, and was therefore less accurate than the other two methods. The study shows that ultrasonography is as reliable a method for confirmation of endotracheal intubation as capnography and is more reliable than clinical method. Besides, ultrasonography is faster than the other two methods.

Anesthetic management of patients undergoing one-step surgical tracheoesophageal fistula: Case series

The anesthetic management of newborns with tracheoesophageal fistula (TEF) and esophageal atresia (EA) can be challenging due to fistula between the airway and esophagus leading to difficulty in perioperative airway management. Maintaining the endotracheal tube (ETT) position during surgical manipulation and adequate ventilation without gastric distention complications is crucial. This study presents two cases of full-term and normal-birthweight newborns with Type C TEF/EA. Both of the patients underwent one-step surgical repair without gastrostomy insertion. Instead of using gastrostomy, correct placement of ETT might be checked by physical examination. Induction of anesthesia was done using volatile inhalational agents and fentanyl as analgetic. For intubation facilitation, spontaneous breath and ventilation were maintained to prevent gastric distention. This report showed that good intubation conditions could be achieved with deep volatile agents and without muscle relaxants. Patients were ventilated with an assisted-controlled technique following their spontaneous breath until the defect was ligated. Hemodynamic was maintained stably in both patients during the operation. Full-term babies with normal birthweight and no other congenital anomalies are generally associated with a better prognosis.

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.

Unusual cause of airway obstruction after nasal intubation with a preformed endotracheal tube.

Unusual cause of airway obstruction after nasal intubation with a preformed endotracheal tube.

Ultrasound is a reliable and faster tool for confirmation of endotracheal intubation compared to chest auscultation and capnography when performed by novice anaesthesia residents - A prospective controlled clinical trial.

Background:Anesthesia trainee may initially take longer time to intubate and unintentionally place the endotracheal tube (ETT) in the esophagus. The present study determined if ultrasound is the fastest method of confirmation of correct placement of ETT compared to capnography, and chest auscultation in trainees.Methods:First year anesthesia residents performed intubation in 120 patients recruited after ethical clearance and informed consent. Time to visualize flutter in trachea, double trachea sign, time to appearance of first and sixth capnography, and time to execute chest auscultation was noted.Results:Ultrasonography was statistically fastest method to determine endotracheal intubation (36.50 ± 15.14 seconds) vs unilateral chest auscultation (50.29 ± 15.50 seconds) vs bilateral chest auscultation (51.90 ± 15.98 seconds) vs capnography first waveform (53.57 ± 15.97 seconds) vs capnography sixth waveform (61.67 ± 15.88 seconds).Conclusion:When teaching endotracheal intubation to novice anesthesia residents using conventional direct laryngoscopy, ultrasonography is the fastest method to confirm correct ETT placement compared to capnograph and chest auscultation. Mentor can guide trainee to direct ETT towards trachea and can promptly detect esophageal intubation by double trachea sign.

Role of ultrasonography in the assessment of correct endotracheal tube placement in neonates.

Role of ultrasonography in the assessment of correct endotracheal tube placement in neonates.

A Persistently High End-Tidal Carbon Dioxide Value: Can This Be Spurious?

AbstractEnd-tidal carbon dioxide (EtCO2) monitoring has now become the standard of care not only during anesthesia but also in intensive care units for patients on mechanical ventilation, emergency department, and pre-hospital settings to confirm and monitor the correct placement of endotracheal tube. It is a non-invasive and continuous method of measuring exhaled carbon dioxide (CO2). Continuous waveform capnography measures EtCO2 and monitors ventilation. EtCO2 often correlates with partial pressure of carbon dioxide in arterial blood (PaCO2) and is a reliable indicator of PaCO2. A rise in EtCO2 often implies increased production of CO2 or decreased excretion (rebreathing, decrease ventilation) of CO2. We report an unusual case where the monitor malfunction per se lead to spuriously increased EtCO2 values without any clinical cause and did not correlate with PaCO2, thereby re-emphasizing that various monitors must always be interpreted in correlation with clinical observation.

Comparison of Upper Airway Ultrasonography with Standard Waveform Capnography and Auscultation to Verify Correct Placement of Endotracheal Tube after Intubation

Comparison of Upper Airway Ultrasonography with Standard Waveform Capnography and Auscultation to Verify Correct Placement of Endotracheal Tube after Intubation

WITHDRAWN: Techniques to ascertain correct endotracheal tube placement in neonates.

The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. We did not identify any studies meeting the criteria for inclusion in this review. There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.

Comparison of Static versus Dynamic Ultrasound for the Detection of Endotracheal Intubation.

IntroductionIn the emergency department setting, it is essential to rapidly and accurately confirm correct endotracheal tube (ETT) placement. Ultrasound is an increasingly studied modality for identifying ETT location. However, there has been significant variation in techniques between studies, with some using the dynamic technique, while others use a static approach. This study compared the static and dynamic techniques to determine which was more accurate for ETT identification.MethodsWe performed this study in a cadaver lab using three different cadavers to represent variations in neck circumference. Cadavers were randomized to either tracheal or esophageal intubation in equal proportions. Blinded sonographers then assessed the location of the ETT using either static or dynamic sonography. We assessed accuracy of sonographer identification of ETT location, time to identification, and operator confidence.ResultsA total of 120 intubations were performed: 62 tracheal intubations and 58 esophageal intubations. The static technique was 93.6% (95% confidence interval [CI] [84.3% to 98.2%]) sensitive and 98.3% specific (95% CI [90.8% to 99.9%]). The dynamic technique was 92.1% (95% CI [82.4% to 97.4%]) sensitive and 91.2% specific (95% CI [80.7% to 97.1%]). The mean time to identification was 6.72 seconds (95% CI [5.53 to 7.9] seconds) in the static technique and 6.4 seconds (95% CI [5.65 to 7.16] seconds) in the dynamic technique. Operator confidence was 4.9/5.0 (95% CI [4.83 to 4.97]) in the static technique and 4.86/5.0 (95% CI [4.78 to 4.94]) in the dynamic technique. There was no statistically significant difference between groups for any of the outcomes.ConclusionThis study demonstrated that both the static and dynamic sonography approaches were rapid and accurate for confirming ETT location with no statistically significant difference between modalities. Further studies are recommended to compare these techniques in ED patients and with more novice sonographers.

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.