Endotracheal Tube Location Research Articles

Comparison of real-time ultrasonography with waveform capnography in verifying endotracheal tube location- An observational study

Immediate post-intubation confirmation of endotracheal tube requires direct observational or secondary gadgets-dependent measures having variable sensitivity and specificity. In this study, dynamic real-time ultrasonography is used for the evaluation of endotracheal tube. The correlation between the gold standard test(Capnography) and the unconventional test(Ultrasonography) is also evaluated.One hundred ASA PS 1, and ASA PS 2 patients were evaluated for endotracheal intubation using real-time ultrasonography. The desired endotracheal intubation was further confirmed by using time capnography. Victorious tracheal intubation was identified using some radiological signs, only one air-mucosa interface with a comet-tail artefact and enhanced posterior acoustic shadowing indicative of endotracheal intubation. Two air-mucosa interfaces with comet-tail artefacts with posterior shadowing were indicative of oesophageal intubation.The mean (SD) ages of the studied patients were 41.25±7.76 Yrs. A total of 87% of patients had endotracheal intubation and 13% had oesophageal intubation based on ultrasonography scan findings. Capnography finding was 91% endotracheal intubations, 9% were true oesophageal. The true positive and true negative rate, positive predictive value and negative predictive values of real-time ultrasonography were 95%, (95% confidence interval (CI) 88% to 98%) 100% (95% CI 62% to 100%), 100% (95% CI 94% to 100%), 69% (95% CI 38% to 89%) respectively. Kappa (k) value was 0.8. Ultrasonography is a portable sensitive screening equipment for ETT position confirmation. There is a strong association between USG findings with time capnography results.

Bilateral vocal cord paralysis and airway obstruction during postoperative period after partial glossectomy

Bilateral vocal cord paralysis is a rare complication of endotracheal intubation, causing serious problems. We report a case of bilateral vocal cord paralysis and airway obstruction in the postoperative period after partial glossectomy. A 61-year-old male patient with diabetes mellitus underwent partial glossectomy under general anesthesia. The anesthesia during surgery was uneventful. After extubation, the patient appeared to have airway obstruction and complained of dyspnea. Flexible fiberoptic laryngoscopy was performed immediately, and the patient was diagnosed with bilateral vocal cord paralysis. Therefore, reintubation was performed. The patient was extubated the following day and discharged with incomplete recovery of vocal cord paralysis. The study findings indicate that inappropriate endotracheal tube location and cuff pressure can cause bilateral vocal cord paralysis. The involvement of head position and tongue traction during glossectomy was suggested in this case. Anesthesiologists should be able to consider and manage bilateral vocal cord paralysis in patients with airway obstruction in the postoperative period.

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.

Comparison of dynamic versus static ultrasound to confirm endotracheal tube depth

IntroductionAfter endotracheal intubation is performed, the location of the endotracheal tube (ETT) is confirmed followed by assessment of ETT depth. Physical examination can be unreliable and chest radiographs can lead to delayed recognition. Ultrasound may facilitate rapid determination of ETT depth at the bedside; however, the ideal technique is unknown. MethodsThis was a randomized trial comparing the static versus dynamic technique for ETT depth assessment using a cadaver model. The ETT was randomized to correct versus deep placement. Seven physicians blinded to ETT location assessed the location using static (direct visualization of an inflated cuff) versus dynamic (active inflation of the ETT cuff) visualization. Outcomes included diagnostic accuracy, time to identification, and operator confidence with subgroup analyses by physician ultrasound experience. Results420 total assessments were performed. The static technique was 99.1% (95% CI 94.8%–100%) sensitive and 97.1% (95% CI 91.9%–99.4%) specific. The dynamic technique was 100% (95% CI 96.7%–100%) sensitive and 100% (95% CI 96.7%–100%) specific. Time to identification was faster for the static technique (6.6 s; 95% CI 5.9–7.4 s) versus the dynamic technique (8.7 s; 95% CI 8.0–9.5 s). Operator confidence was lower for the static technique (4.4/5.0; 95% CI 4.3–4.5) versus the dynamic technique (4.7/5.0; 95% CI 4.6–4.8). There were no differences in the findings when assessed among expert or non-expert sonographers. ConclusionThere was no statistically significant difference in the accuracy of ETT depth identification between the static or dynamic technique. However, utilizing the dynamic technique showed a statistically significant improvement in sonographer confidence and a concomitant increase in time to identification.

The diagnostic accuracy of an inclusive three-window ultrasonography assessment for the rapid authentication of endotracheal tube position in RICU

BackgroundAssurance of proper endotracheal tube (ETT) location is crucial immediately after intubation as undiagnosed esophageal intubation can be catastrophic. The primary purpose for this study is to determine the diagnostic accuracy of to evaluate the accuracy of an inclusive three-window ultrasonography assessment for the rapid authentication of endotracheal tube position in the intensive care unit (RICU) with reference to Co2 monitors (capnography) (the gold standard technique), The study included 100 patients who needed emergency intubation in the ICU of Aswan university hospital. Upon entrance to ICU, intubations was done by the residents and collective bedside three-windows ultra-sonography (tracheal, lung, diaphragmatic ultra-sonography) was carried out instantly after intubation Subsequently, the correct position of the endotracheal tube was established by the resident investigator via the use a capnometer.ResultsWaveform capnography revealed endotracheal intubation in 80 cases (80%) and esophageal intubation in 20 cases (20%). However, trans-tracheal ultra-sonography (TUS) was able to detect endotracheal intubation in 78 cases (78%) and esophageal intubation in 22 cases (22%) patients. SLS detected only 17 esophageal intubations from 20 cases detected by CO2 detectors. DUS was able to detect proper endotracheal intubation in 77 cases (77%) and esophageal intubation in 23 cases (23%). However, it detected only 17 esophageal intubations from 20 cases detected by Co2 detectors.ConclusionsUltra-sonography, as recently introduced practice for validation of correct endotracheal tube location has both high accuracy and safety profile and can be used as a primary authentication technique.Trial registrationNCT05747248

Comparison of Upper Airway Ultrasonography With End-Tidal Capnography for the Confirmation of Endotracheal Tube Placement in Patients Requiring General Anesthesia

Introduction End-tidal capnography (EtCO2)has been the gold standard method for confirmation of endotracheal intubation.Upper airway ultrasonography (USG) is a new promising method for confirming endotracheal tube (ETT) placement and has the potential to become the first-line non-invasive airway assessment tool in the future thanks to widespread POCUS knowledge, greater technology improvements, portability, and availability of ultrasound in the majority of essential areas. Hence our study aimed to compare upper airway USGand EtCO2 for the confirmation of ETTplacement in patients undergoing general anesthesia. Aim To compare the upper airway USG with EtCO2for confirmation of ETTplacement in patients requiring general anesthesia for elective surgical procedures.The objectives of the study were to compare the time taken for confirmation, and the number of correct identification of tracheal and esophageal intubation by both upper airway USG and EtCO2. Materials and methods After obtaining institutional ethical committee (IEC) approval, a prospective randomized comparative study involving 150 patients under American Society of Anesthesiologists (ASA) grade I and II requiring endotracheal intubation for elective surgeries under general anesthesia was randomized into two groups, Group U-upper airway USG and Group E-EtCO2with 75 patients in each group. ETT placement confirmation was done by upper airway USG in Group U andby EtCO2in Group E and the time taken for confirmation of ETT placement and correct identification of esophageal and tracheal intubation by USG and EtCO2was noted. Results The demographic details among both groupswere statistically insignificant. Upper airway USG had a faster average confirmation time of 16.41 seconds when compared to EtCO2 which took an average confirmation time of 23.56 seconds. In our study, upper airway USG was able to identify esophageal intubation with 100% specificity. Conclusion Upper airway USG can be a reliable method and can be employed as a standard method for confirmation of ETT location in patients undergoing elective surgeries under general anesthesia when compared to EtCO2.

Using a bedside ultrasound (US), an emerging technology, to confirm endotracheal tube (ETT) location in adults in emergency department

Introduction: Airway management is the most important aspect of patient treatment in emergency medicine. Prompt confirmation of Endotracheal Tube (ETT) in larynx is imperative for avoiding complications in sick patient. With quick learning graph, Point of Care Ultrasound (POCUS) has high sensitivity and specificity for detection of ETT in place.
 
 Method: A prospective observational study was conducted at adult Emergency Department of Tribhuvan University Teaching Hospital among patients undergoing intubation for various reasons. Transtracheal POCUS was used to confirm the tube placement. Time to confirm tube by POCUS in trachea and by bilateral chest auscultation was noted.
 
 Result: Of the 71 intubations, 68 were correctly identified to be in trachea and 3 in esophagus, resulting in sensitivity and specificity of 100% each. Transtracheal POCUS was the fastest method to determine endotracheal intubation (8.08 ± 1.69 seconds) compared to bilateral chest auscultation (22.37 ± 3.45 seconds).
 
 Conclusion: With high sensitivity and NPV for confirmation of correct endotracheal tube intubation and early detection, transtracheal POCUS in emergency could be a useful tool for prompt localization of ETT and instant action needed before final confirmation by other means.

Ultrasonographic evaluation of endotracheal tube position in newborns with CHD.

In this prospective observational clinical study, we performed point-of-care ultrasound for endotracheal tube localisation in 65 intubated newborns with critical CHD. After routine radiography, each patient underwent point-of-care ultrasound examination with a portable ultrasonography device for endotracheal tube end-carina measurement. Endotracheal tube end-carina measurements on chest radiographs were compared with ultrasound images. The mean gestational age and birth weight were 37.8 ± 2.19 weeks and 2888 ± 595 g, respectively. Ultrasound images were obtained after an average of 2.08 ± 1.6 hours from the radiographs. The average ultrasound time allocated to each patient was 5 minutes. The mean endotracheal tube tip-to-carina distance on chest X-ray and ultrasound were optimally 1.33 ± 0.64 cm and 1.43 ± 0.67 cm, respectively. There was no significant difference between chest X-ray and ultrasound measurements in endotracheal tube end-carina distance values evaluated by the Bland-Altman method (mean difference 0.10 cm, p = 0.068). There was a linear correlation between the endotracheal tube tip-carina distance in ultrasound and radiography evaluation (r2 = 0.60, p < 0.001). It has been concluded that critical CHDs are frequently accompanied by vascular anomalies, and the endotracheal tube tip-carina distance measurement can be used by determining the carina section as a guide point in the ultrasonographic evaluation of the endotracheal tube location in this patient population.

Diagnostic accuracy of ultrasound to confirm endotracheal tube depth

IntroductionEndotracheal intubation is commonly performed in the Emergency Department. Traditional measures for estimating and confirming the endotracheal tube (ETT) depth may be inaccurate or lead to delayed recognition. Ultrasound may offer a rapid tool to confirm ETT depth at the bedside. MethodsThis was a randomized trial assessing the diagnostic accuracy of ultrasound to confirm ETT depth. Three cadavers were intubated in a random sequence with the ETT placed high (directly below the vocal cords), middle (2 cm above the carina), or deep (ETT at the carina). Seven blinded sonographers assessed the depth of the ETT using ultrasound. Outcomes included diagnostic accuracy of sonographer identification, time to identification, and operator confidence based upon ETT location. A subgroup analysis was performed to assess diagnostic accuracy by operator confidence. Results441 total assessments were performed (154 high, 154 middle, and 133 deep ETT placements). Overall accuracy was 84.8% (95% CI 81.1% to 88.0%). When placed high, ultrasound was 82.5% sensitive (95% CI 75.5% to 88.1%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 15.3 s (95% CI 13.6–17.0) and a mean operator confidence of 3.9/5.0 (95% CI 3.7–4.1). When the ETT was placed in the middle, ultrasound was 83.8% sensitive (95% CI 77.0% to 89.2%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 16.7 s (95% CI 14.6–18.8) and a mean operator confidence of 3.7/5.0 (95% CI 3.5–3.9). When the ETT was placed deep, ultrasound was 88.0% sensitive (95% CI 81.2% to 93.0%) and 92.2% specific (95% CI 88.6% to 94.6%) with a mean time to identification of 19.0 s (95% CI 17.3–20.7) and a mean operator confidence of 3.4/5.0 (95% CI 3.2–3.6). Sonographers were significantly more accurate when they reported a higher confidence score. ConclusionUltrasound was moderately accurate for identifying the ETT location in a cadaveric model and was more accurate when sonographers felt confident with their visualization. Future research should determine the accuracy of combining transtracheal ultrasound with lung sliding and other modifications to improve the accuracy.

Comparison of saline versus air for identifying endotracheal intubation with ultrasound

IntroductionAfter intubation has been performed, it is important to rapidly confirm the correct location of the endotracheal tube (ETT). Multiple techniques have been described, each with different limitations. Ultrasound has been increasingly recognized as an alternate modality for identifying the ETT location. However, it can be challenging to visualize the air-filled ETT cuff. Saline insufflation of the ETT cuff has been suggested to improve visualization of the ETT but data are limited. Our study sought to compare the diagnostic accuracy of air versus saline ETT cuff inflation on the diagnostic accuracy of intubation. MethodsThis was a randomized trial comparing air versus saline cuff inflation using a cadaver model. Adult cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and air versus saline. Blinded sonographers assessed the location of the ETT using the static technique. Outcomes included accuracy of sonographer identification, time to identification, and operator confidence. Results480 total assessments were performed. When using air, ultrasound was 95.8% sensitive (95% CI 90.5% to 98.6%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 8.5 s (95% CI 7.6 s to 9.4 s) and a mean operator confidence of 4.32/5.0 (95% CI 4.21 to 4.42). When using saline, ultrasound was 100% sensitive (95% CI 97.0% to 100%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 6.3 s (95% CI 5.9 s to 6.8 s) and a mean operator confidence of 4.52/5.0 (95% CI 4.44 to 4.60). ConclusionThere was no statistically significant difference between air versus saline for intubation confirmation. However, saline was associated with fewer false negatives. Additionally, time to confirmation was faster and operator confidence was higher with the saline group. Further studies should determine if the outcomes would change with more novice sonographers or in specific patient populations.

Determining Carina and Clavicular Distance-Dependent Positioning of Endotracheal Tube in Critically Ill Patients: An Artificial Intelligence-Based Approach.

Early and accurate prediction of endotracheal tube (ETT) location is pivotal for critically ill patients. Automatic and timely detection of faulty ETT locations from chest X-ray images may avert patients' morbidity and mortality. Therefore, we designed convolutional neural network (CNN)-based algorithms to evaluate ETT position appropriateness relative to four detected key points, including tracheal tube end, carina, and left/right clavicular heads on chest radiographs. We estimated distances from the tube end to tracheal carina and the midpoint of clavicular heads. A DenseNet121 encoder transformed images into embedding features, and a CNN-based decoder generated the probability distributions. Based on four sets of tube-to-carina distance-dependent parameters (i.e., (i) 30-70 mm, (ii) 30-60 mm, (iii) 20-60 mm, and (iv) 20-55 mm), corresponding models were generated, and their accuracy was evaluated through the predicted L1 distance to ground-truth coordinates. Based on tube-to-carina and tube-to-clavicle distances, the highest sensitivity, and specificity of 92.85% and 84.62% respectively, were revealed for 20-55 mm. This implies that tube-to-carina distance between 20 and 55 mm is optimal for an AI-based key point appropriateness detection system and is empirically comparable to physicians' consensus.

Screening Performance Characteristics of Ultrasonography in Confirmation of Endotracheal Intubation; a Systematic Review and Meta-analysis.

Introduction:Recent studies have suggested that point-of-care ultrasonography can be used for confirming the placement of endotracheal tube. This systematic review and meta-analysis aimed to investigate the sensitivity and specificity of ultrasonography for confirming endotracheal tube placement. Methods:In this meta-analysis, systematic search of the previous published papers investigating the diagnostic accuracy of ultrasonography for confirmation of endotracheal tube placement was performed. Seven electronic databases, including PubMed, Scopus, Google Scholar, EBSCO, EMBASE, Web of Science, and Cochrane Database were searched up to July 2021, for all relevant articles published in English on this topic. Meta-DiSc version 1.4 software was used for statistical analysis.Results:The estimated pooled sensitivity and specificity of ultrasonography for confirmation of endotracheal tube location were 0.98 (95% CI: 0.98–0.99) and 0.94 (95% CI 0.91–0.96), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 5.94 (95% CI 4.41–7.98) and 0.03 (95% CI: 0.02-0.04), respectively. The diagnostic odds ratio of ultrasonography was 281.47 and the area under hierarchical summary receiver operating characteristic (HSROC) revealed an appropriate accuracy of 0.98.Conclusion:Ultrasonography has high diagnostic accuracy and can be used as a promising tool for confirmation of endotracheal tube placement, especially in critically ill patients or when capnography is not available, or its result is equivocal.

Identification and Localization of Endotracheal Tube on Chest Radiographs Using a Cascaded Convolutional Neural Network Approach

Rapid and accurate assessment of endotracheal tube (ETT) location is essential in the intensive care unit (ICU) setting, where timely identification of a mispositioned support device may prevent significant patient morbidity and mortality. This study proposes a series of deep learning-based algorithms which together iteratively identify and localize the position of an ETT relative to the carina on chest radiographs. Using the open-source MIMIC Chest X-Ray (MIMIC-CXR) dataset, a total of 16,000 patients were identified (8000 patients with an ETT and 8000 patients without an ETT). Three different convolutional neural network (CNN) algorithms were created. First, a regression loss function CNN was trained to estimate the coordinate location of the carina, which was then used to crop the original radiograph to the distal trachea and proximal bronchi. Second, a classifier CNN was trained using the cropped inputs to determine the presence or absence of an ETT. Finally, for radiographs containing an ETT, a third regression CNN was trained to both refine the coordinate location of the carina and identify the location of the distal ETT tip. Model accuracy was assessed by comparing the absolute distance of prediction and ground-truth coordinates as well as CNN predictions relative to measurements documented in original radiologic reports. Upon five-fold cross validation, binary classification for the presence or absence of ETT demonstrated an accuracy, sensitivity, specificity, PPV, NPV, and AUC of 97.14%, 97.37%, 96.89%, 97.12%, 97.15%, and 99.58% respectively. CNN predicted coordinate location of the carina, and distal ETT tip was estimated within a median error of 0.46 cm and 0.60 cm from ground-truth annotations respectively. Overall final CNN assessment of distance between the carina and distal ETT tip was predicted within a median error of 0.60 cm from manual ground-truth annotations, and a median error of 0.66 cm from measurements documented in the original radiology reports. A serial cascaded CNN approach demonstrates high accuracy for both identification and localization of ETT tip and carina on chest radiographs. High performance of the proposed multi-step strategy is in part related to iterative refinement of coordinate localization as well as explicit image cropping which focuses algorithm attention to key anatomic regions of interest.

Invasive Mechanical Ventilation for Acute Viral Bronchiolitis: Retrospective Multicenter Cohort Study.

Bronchiolitis is a leading cause of PICU admission and a major contributor to resource utilization during the winter season. Management in mechanically ventilated patients with bronchiolitis is not standardized. We aimed to assess whether variations exist in management between the centers and then to assess if differences in PICU outcomes are found. Retrospective cohort study. Three tertiary PICUs (Centers A, B, and C) in London, United Kingdom. Patients under 1 year of age (n = 462) who received invasive mechanical ventilation for acute viral bronchiolitis from 2012-2016. None. Retrospective cohort study. Data collected include all sedative agents administered, 48 hour cumulative fluid balance and location of endotracheal tube (oral or nasal). Primary outcome was duration of invasive mechanical ventilation. A generalized linear model was used to test for differences in duration of invasive mechanical ventilation between centers after adjustment for confounders: corrected gestational age, oxygen saturation index, bacterial coinfection, prematurity, respiratory syncytial virus status, risk of mortality score and comorbidity. Baseline characteristics were similar, other than a higher risk of mortality score at center A and higher admission oxygen saturation index at center C. Center A was associated with utilization of the most benzodiazepine and opiate sedation, the fewest nasal endotracheal tubes, and the highest mean cumulative fluid balance at 48 hours.Center A had an adjusted mean duration of invasive mechanical ventilation that was 44% longer than center C (95% CI, 25-66%; p < 0.001).The majority of confounders had an association with the duration of invasive mechanical ventilation; all were biologically plausible. Corrected gestational age was negatively associated with the duration of invasive mechanical ventilation for preterm infants less than 32 weeks, but not for term or 32-37 week infants (interaction effect). This meant that at a corrected age of 0 months, a less than 32-week infant had a mean duration that was 55% greater than a term infant: this effect had disappeared by 8 months old. Between-center variations exist in both practices and outcomes. The relationship between these two findings could be further tested through implementation science with "optimal care bundles."

Ultrasound for Intubation Confirmation: A Randomized Controlled Study among Emergency Medicine Residents

Confirmation of endotracheal tube (ETT) placement during intubation is a critical skill for emergency medicine (EM) residents; airway ultrasonography has been suggested as an accessible and accurate method of ETT confirmation. Here, we investigated the accuracy with which EM residents could identify ETT location in cadavers using different ultrasound modes. EM attendings intubated either the trachea or the esophagus of a cadaver, and blinded residents identified ETT position using either B-mode or B-mode plus color Doppler. Residents correctly identified ETT location in 1075 of 1203 trials (89.4%); performance improved with post-graduate year (residents in post-graduate year 3 had 97.8% accurate identifications). There were 556 (91.7%) correct identifications made with B-mode and 519 (86.9%) with B-mode plus color Doppler (p value = 0.007); thus, accuracy did not improve with addition of color Doppler to B-mode. Further research is needed on the efficacy of different ultrasound modes in confirming ETT placement in live intubations.

Ability of Critical Care Medics to Confirm Endotracheal Tube Placement by Ultrasound.

The Advanced Cardiac Life Support (ACLS) guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement. While this method is employed in the emergency department under the guidance of the most recent American College of Emergency Physicians (ACEP; Irving, Texas USA) guidelines, it has yet to gain wide acceptance in the prehospital setting where it has the potential for greater impact. The objective of this study to is determine if training critical care medics using simulation was a feasible and reliable method to learn this skill. Twenty critical care paramedics with no previous experience with point-of-care ultrasound volunteered for advanced training in prehospital ultrasound. Four ultrasound fellowship trained emergency physicians proctored two three-hour training sessions. Each session included a brief introduction to ultrasound "knobology," normal sonographic neck and lung anatomy, and how to identify ETT placement within the trachea or esophagus. Immediately following this, the paramedics were tested with five simulated case scenarios using pre-obtained images that demonstrated a correctly placed ETT, an esophageal intubation, a bronchial intubation, and an improperly functioning ETT. Their accuracy, length of time to respond, and comfort with using ultrasound were all assessed. All 20 critical care medics completed the training and testing session. During the five scenarios, 37/40 (92.5%) identified the correct endotracheal placements, 18/20 (90.0%) identified the esophageal intubations, 18/20 (90.0%) identified the bronchial intubation, and 20/20 (100.0%) identified the ETT malfunctions correctly. The average time to diagnosis was 10.6 seconds for proper placement, 15.5 seconds for esophageal, 15.6 seconds for bronchial intubation, and 11.8 seconds for ETT malfunction. The use of ultrasound to confirm ETT placement can be effectively taught to critical care medics using a short, simulation-based training session. Further studies on implementation into patient care scenarios are needed.

A prospective observational trial evaluating factors predictive of accurate endotracheal tube positioning in neonates and small infants.

There is a high incidence of endotracheal tube malposition in neonates and small infants. Yet, verification of accurate endotracheal tube location via radiographic imaging involves radiation exposure. This study aimed to identify demographic and clinical parameters associated with accurate endotracheal tube positioning. We conducted a prospective single-center study with term and preterm neonates and small infants between January 2018 and November 2019. We investigated correlations between ten variables and accurate endotracheal tube position. One hundred and sixty eight nasal intubations in 139 patients (weight 390-5000g) were analyzed. An accurate tube position was confirmed by radiographic imaging in 71.4% of the intubations. The endotracheal tube was high in 8.3% and low in 20.2% of the cases. Male gender was the only variable that significantly correlated with an accurate endotracheal tube position (OR 2.5; 95% CI: 1.3, 5.0; P=.010). So far, no parameter has proven to be able to predict accurate endotracheal tube position in neonates reliably. These findings emphasize the indispensability of postintubation imaging in neonates and small infants.

Impact of endotracheal tube twisting on the diagnostic accuracy of ultrasound for intubation confirmation

IntroductionUltrasound is a readily-available technique used to identify accurate placement of an endotracheal tube (ETT) after an intubation attempt. There is limited research on using manipulation of the ETT to improve the diagnostic accuracy of ETT location confirmation. Our study sought to directly assess whether ETT twisting during the standard grayscale technique influenced the accuracy of intubation confirmation by ultrasound. MethodsThe study was performed using two different fresh cadavers. During each trial, the cadavers were randomized to either tracheal or esophageal intubation. Three blinded, ultrasound fellowship-trained sonographers assessed the location of the ETT post-intubation alternating between using either a technique with no ETT movement or a technique with ETT twisting. In the latter technique, the sonographers manipulated the ETT in using a side-to-side, twisting motion while performing the ultrasound exam. The study measured the accuracy of ETT location identification, time to identification, and sonographer confidence. Results540 assessments were performed with equal numbers of tracheal and esophageal intubations. The accuracy of ultrasound using the static technique was 97.8% (95% CI 95.2% to 99.0%) and the accuracy using the ETT twisting technique was 100% (95% CI 98.6% to 100%). The ETT twisting group showed a faster time to identification with a mean time to identification of 4.97 s (95% CI 4.36 to 5.57 s) compared to 6.87 s (95% CI 6.30 to 7.44 s) for the static ETT group. Operator confidence was also higher in the ETT twisting group at 4.84/5.0 (95% CI 4.79 to 4.90) compared to 4.71/5.0 (95% CI 4.63 to 4.78) in the static ETT group. ConclusionThere was no statistically significant difference in the accuracy of ETT location identification between the two groups. However, utilizing the ETT twisting technique showed a statistically significant improvement in the time to identification and sonographer confidence.

Which endotracheal tube location minimises the device-related pressure ulcer risk: The centre or a corner of the mouth?

The use of an endotracheal tube (ETT), which is required for any mechanical ventilation procedure, involves an inherent risk for facial skin, lip, and mucosal pressure ulcers. The ETT is one of the most common devices associated with medical device-related pressure ulcers (MDRPUs) among surgical and intensive care unit patients. In the present work, we investigated, for the first time in the literature, the biomechanical effects of the presence and positioning of an ETT in the mouth on lip, mucosal and surrounding facial skin loads. Using two anatomically realistic finite element model variants, two ETT locations were simulated and compared, at the centre versus the corner of the mouth. Our study shows that a central location of the ETT inflicted greater lip and mucosal stress values, but a corner location caused a more widespread and diffused lip, mucosal and facial skin stress exposure. Accordingly, we cannot recommend a "safer" location for ETTs in the mouth; additional preventative measures such as dedicated dressing materials or special cushioning pads applied prophylactically, should be developed to protect from MDRPUs associated with ETT usage. The present modelling framework can be used to study the biomechanical efficacy of such protective technologies, and can therefore aid in the prevention of ETT-caused MDRPUs.

Determination of optimal endotracheal tube tip depth from the gum in neonates by X-ray and ultrasound

Background/objective: Proper placement of endotracheal tube (ETT) in the midtrachea is essential. Initial depth of placement of oral ETT from the lips is commonly estimated based on weight (“7-8-9 rule”), gestational age, or nasal-tragus distance. However, these measurements can be altered by superficial factors and the mobility of the lips relative to the airway, so the upper alveolar ridge (gum) may provide a superior landmark. Also, confirmation of ETT tip position by point of care ultrasound (POC-US) is noninvasive and may enable localization of the ETT tip in real time. The objective of this study is to define optimal initial ETT depth from the gum in infants relative to weight, and to compare the efficacy of POC-US with standard chest X-ray (CXR) for confirming ETT tip position.Methods: Neonates requiring oral intubation were enrolled. At the time of CXR that were obtained for clinical indications, the position of the ETT at both the lip and gum were recorded. “Optimal” ETT placement in midtrachea (from lip and gum) was calculated based on the observed measurements and the distance of the ETT tip from the carina on CXR. Linear regression was used to model ideal placement of ETT, as a function of weight. POC-US was performed using a 10 MHz cardiac probe and high parasternal view. Distance from the ETT bevel to the superior aspect of the right pulmonary artery, which is at the level of carina, was measured using electronic calipers.Results: Infants were recruited at a median age of 3 days (n = 75), weight 1300 g, and corrected gestational age 31.6 ± 5.8 weeks. The regression equation for optimal placement from the gum (in cm) was 5.21 + 1.03 × weight (kg). Using estimates of 5 or 5.5 cm + weight (kg) to the gum yielded accuracy similar or superior to the 7-8-9 rule to the lip. Most of the variability in ideal placement of ETT tip from the gum was determined by weight (R2 = 0.83). The difference between optimal placement using lip and gum was 0.51 ± 0.24 cm. ETT location by POC-US (n = 40) was in substantial agreement with CXR (intraclass correlation coefficient 0.95, 95% CI: 0.92, 0.98).Conclusions: Marking oral ETT placement to the gum is feasible, with optimal depth of about 5.2 cm + weight (kg), across all weight categories. POC-US can be used for rapid confirmation of continued ideal ETT tip location, with accuracy similar to CXR. Further studies will be needed to determine whether marking ETT depth to the gum or using POC-US achieves the goal of decreased complications of ETT misplacement or displacement.