Esophageal Detector Device Research Articles

Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis.

Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of unrecognised oesophageal intubation. We conducted a systematic review and meta-analysis of the diagnostic accuracy of five clinical examination tests and the oesophageal detector device when used to confirm tracheal intubation. We searched four databases for studies reporting index clinical tests against a reference standard, from inception to 28 February 2023. We included 49 studies involving 10,654 participants. Methodological quality was overall moderate to high. We looked at misting (three studies, 115 participants); lung auscultation (three studies, 217 participants); combined lung and epigastric auscultation (four studies, 506 participants); the oesophageal detector device (25 studies, 3024 participants); 'hang-up' (two non-human studies); and chest rise (one non-human study). The reference standards used were capnography (22 studies); direct vision (10 studies); and bronchoscopy (three studies). When used to confirm tracheal intubation, misting has a false positive rate (95%CI) of 0.69 (0.43-0.87); lung auscultation 0.14 (0.08-0.23); five-point auscultation 0.18 (0.08-0.36); and the oesophageal detector device 0.05 (0.02-0.09). Tests to exclude events that invariably lead to severe damage or death must have a negligible false positive rate. Misting or auscultation have too high a false positive rate to reliably exclude oesophageal intubation and there is insufficient evidence to support the use of 'hang-up' or chest rise. The oesophageal detector device may be considered where other more reliable means are not available, though waveform capnography remains the reference standard for confirmation of tracheal intubation.

Preventing unrecognised oesophageal intubation.

Major harm from unrecognised oesophageal intubation continues, despite the 2018 Royal College of Anaesthetists' 'no trace, wrong place' campaign. It is likely that publicly reported cases represent a fraction of real occurrences. This article summarises a 2022 consensus guideline on the prevention of unrecognised oesophageal intubation from the Project for Universal Management of Airway and international airway societies. The guideline is written for all airway operators and assistants, in any clinical setting, and readers are advised to deepen their understanding by studying the original guideline. The recommendations include how to avoid and recognise oesophageal intubation as well as a set of logical actions to take when it is a plausible possibility, even if it is not suspected. The guideline emphasises the importance of videolaryngoscopy, capnography and oxygen saturation monitoring for all tracheal intubations, wherever performed. It introduces the concept of sustained exhaled carbon dioxide, which is central to identifying oesophageal intubation, and acting to prevent progression to unrecognised oesophageal intubation. In the absence of sustained exhaled carbon dioxide, the default action is to remove the tube. This will mean some tracheal placed tubes are removed but based on a risk-benefit analysis, this is desirable. The tube should only be left in place if there is clear danger in removing it and in this event, its position should be confirmed, using repeat videolaryngoscopy plus one other of bronchoscopy, skilled ultrasound or use of an oesophageal detector device. The importance of human factors is underlined; for instance, the value of a shared and vocalised report of videolaryngoscopy view and trained assistants working with the operator to confirm whether the criteria for sustained exhaled carbon dioxide are met, to minimise error and improve team working.

The Most Accurate and Fastest Method for Confirmation of Endotracheal Intubation

Tracheal intubation and confirming correct placement of tracheal tube is one of the most important subjects in patients who need airway management (1). Gold standard method of confirmation is capnography, but it is just applicable in patients with tangible cardiac output. Other methods of confirming endotracheal intubation such as hearing gurgling sounds in epigastria, auscultation of lungs sounds, esophageal detector device, and chest radiography can be used for this purpose (2). Recently an exact real time, contrary to other methods, method of confirming endotracheal intubation has been developed which is direct visualization of tracheal tube passage through trachea with sonography. Considering the advantages of sonography, it is strongly recommended for the confirmation of endotracheal intubation(3).

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.

Tracheal Wall Collapse Produced by Esophageal Detector Devices in a Porcine Cardiac Arrest Model

To the Editor Schuh et al.1 compared 3 esophageal detector devices (EDDs) for detecting tracheal and esophageal intubation in pigs, before and after inducing cardiac arrest. They concluded that false-negative results (no reinflation of the bulb with the tracheal tube in the trachea) with one of the devices were caused by decreased tone of the posterior tracheal wall during cardiac arrest. We have 2 issues regarding their interpretation of these results. First, among the factors affecting the performance of EDDs are (a) whether the self-inflating bulb (SIB) is compressed before or after being attached to the tracheal tube, and (b) a decreased functional residual capacity.2 Schuh et al. did not specify whether the bulb was compressed before or after being attached to the tracheal tube.1 In our investigation of the efficacy of the EDD in confirming tracheal intubation in morbidly obese patients, we found that compressing the SIB after connection to the tracheal tube decreased the occurrence of false-negative results (from 24% to 4%).3 Second, an altered functional residual capacity/closing capacity relationship after anesthetic induction in supine patients results in decreased caliber of airways. In addition, excessive negative pressure generated by an SIB (more negative than −36.7 mm Hg) can result in collapse of large airways, invagination of the posterior tracheal wall, and consequently no reinflation of the SIB.3 SIBs used clinically in prior studies generate negative pressures between −55 and −68 mm Hg,4,5 whereas the SIBs used by Schuh et al.1 generate greater negative pressures in excess of −100 mm Hg. The authors' findings do not support their proposed mechanism for the false-negative results. If decreased tone was an important factor, then there should have been more false-negative results as the postarrest phase progressed. We propose that their false-negative results were caused by the excessive negative pressure generated by Bulb #2 (−110.2 mm Hg). David J. Lang, DO M. Ramez Salem, MD Department of Anesthesiology Advocate Illinois Masonic Medical Center University of Illinois College of Medicine Chicago, Illinois [email protected]

Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults

Failed airway is the anesthesiologist's nightmare. Although conventional preoxygenation can provide time, atelectasis occurs in the dependent areas of the lungs immediately after anesthetic induction. Therefore, alternatives such as positive end-expiratory pressure (PEEP) and head-up tilt during preoxygenation have been explored. We compared the conventional preoxygenation technique (group C) with 20º head-up tilt (group H) and 5cmH(2)O PEEP (group P) in non-obese individuals for non-hypoxic apnea duration. A total of 45 patients were enrolled (15 in each group). After 5min of preoxygenation, intubation was performed after induction of anesthesia with thiopentone and succinylcholine. After confirming the tracheal intubation by esophageal detector device and capnogram, all patients were administered vecuronium to maintain neuromuscular blockade and midazolam to prevent awareness. Post-induction, patients in all groups were left apneic in supine position with the tracheal tube exposed to atmosphere till the SpO(2) dropped to 93% or 10min of safe apnea was achieved. The demographic data were comparable. Non-hypoxic apnea duration was higher with group H (452±71s) compared to group C (364±83s, P = 0.030). Group P did not show significant increase in the duration of non-hypoxic apnea (413±86s). There were no adverse outcomes or events. Preoxygenation is clinically and statistically more efficacious and by inference more efficient in the 20º head-up position than with conventional technique in non-obese healthy adults. Although application of 5cmH(2)O PEEP provides longer duration of non-hypoxic apnea compared to conventional technique, it is not statistically significant.

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Part 8: Advanced Life Support

Part 8: Advanced Life Support

Confirmation of Needle Cricothyroidotomy Using an Esophageal Detector Device in a Porcine Model

The difficult intubation is one of the most trying situations encountered in airway management. Transtracheal jet ventilation via needle cricothyroidotomy can provide temporary oxygenation in this critical situation in a minimally invasive fashion. The esophageal detector device (EDD) has been previously shown to be effective in determining the tracheal placement of endotracheal tubes. In this experiment, three commonly available EDDs are utilized to accurately identify 15 of 15 intratracheal placements of a 16-gauge i.v. catheter in five cadaveric domestic swine. The incorporation of EDDs in i.v. catheter placement for needle cricothyroidotomy is shown to be effective and merits further study. Likewise, further investigation is needed to identify a standardized apparatus for needle cricothyroidotomy in emergent situations.

Negative Intratracheal Pressure Produced by Esophageal Detector Devices Causes Tracheal Wall Collapse in a Porcine Cardiac Arrest Model

Esophageal detector devices (EDDs) impose negative pressure on the trachea or esophagus to verify endotracheal tube (ETT) position. In cardiac arrest, the smooth muscle of the lower esophageal sphincter relaxes in a time-dependent and irreversible manner. If relaxation also occurs in the muscular posterior tracheal wall, it could predispose tracheal invagination or collapse with negative pressure, potentially yielding false-negative (tracheal ETT, EDD indicates esophagus) results. We compared 3 different EDDs in their ability to correctly discriminate tracheal and esophageal intubation. ETTs were placed into the trachea and esophagus of 5 domestic swine, and bronchoscopy was used to visualize the trachea while 3 EDDs were tested. Tracheal wall activity was observed before and after induced cardiac arrest. Tracheal ETTs were aspirated with increasing negative force and pressures at initial wall movement and >50% tracheal lumen obliteration were recorded. Measurements were repeated at 4, 8, and 12 minutes postarrest and pressures at tracheal wall collapse pre- and postarrest were determined. EDDs were also tested on esophageal ETTs prearrest and at 6 and 10 minutes postarrest. In a closed system, each EDD generated more than -100 cm H(2)O pressure. Average prearrest pressure at tracheal collapse was -112 cm H(2)O. Average postarrest collapse pressures were -68, -66, and -54 cm H(2)O at 4, 8, and 12 minutes postarrest. One EDD consistently gave equivocal results; the remaining 2 gave accurate results in all subjects. Most observed movement was insufficient to cause device failure although tracheal wall movement was noted in all postarrest EDD trials. Esophageal intubation was correctly determined at all times pre- and postarrest. These findings describe a mechanism for false-negative results from decreased posterior tracheal wall tone during cardiac arrest. Further studies are required to elucidate factors contributing to its occurrence and impact on EDD use.

235: The Primary Confirmation of Endotracheal Intubation by Ultrasonography in the Emergency Department

Primary methods identifying endotracheal intubation are various such as direct visualization of the vocal cords, chest rising after intubation, and auscultation of both lungs. Secondary confirmation methods are also various such as detection of end-tidal carbon dioxide level, esophageal detector device, and chest X-ray. The aim of this study was to verify that ultrasonography (US) is useful as a primary confirmation method.

Frova intubating catheter position can be determined with aspirating oesophageal detection device

Intubating catheters (e.g. gum-elastic bougie) are an invaluable adjunct in the management of a difficult airway. Traditional tactile 'click' (from tracheal rings) and 'hold up' (from carina or bronchus) techniques for confirming tracheal placement are, however, fallible, and definitive placement can only be confirmed following passage of the endotracheal tube. Ensuing delays might contribute to the development of arterial hypoxaemia. Our aim was to determine whether an aspirating oesophageal detector device might be useful for confirming placement of the Frova intubating catheter (a hollow-bore intubating catheter). Eighteen adult patients (American Society of Anaesthiology category 1-2) undergoing elective surgery had the Frova intubating catheter alternately placed in the trachea, or oesophagus, following induction of anaesthesia. Catheter position was assessed using an aspirating oesophageal detector device prior to tracheal intubation. The oesophageal detector device correctly predicted tracheal (n = 18) and oesophageal (n = 18) placement in all patients. All procedures were completed in less than 15 s. In the operating theatre setting the aspirating oesophageal detector device reliably predicts tracheal and oesophageal placement of the Frova intubating catheter.

The Combitube, Self-Inflating Bulb, and Colorimetric Carbon Dioxide Detector to Advance Airway Management in the First Echelon of the Battlefield

Combat lifesavers and Army medics are regular combat soldiers who possess skills that enable them to provide lifesaving assistance to combat casualties. Although their training is not equal to that of paramedics, combat lifesavers and Army medics are trained to assess casualties for airway obstruction, as well as the presence or absence of spontaneous ventilation. They are also familiar with the same basic airway maneuvers that are required for blind insertion of the esophageal-tracheal double-lumen airway (ETDLA). Use of the ETDLA in combination with an esophageal detector device and a colorimetric carbon dioxide detector would require skill similar to that which they already possess in performing many mission-essential and combat lifesaver tasks. Because the U.S. Army has introduced the ETDLA for use, it is important that providers at all echelons understand the dynamics of the ETDLA. Inclusion of the ETDLA, esophageal detector device, and colorimetric carbon dioxide detector in combination with the bag-valve ventilation device could provide a viable alternative to mouth-to-mouth rescue breathing with the oral airway, as currently used by combat lifesavers on the battlefield. Improved airway management, in conjunction with other lifesaving measures, could potentially improve survival rates for combat casualties and assist in stabilizing them for evacuation to higher echelons of combat medical care.

2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Basic Life Support

2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Basic Life Support

Part 4: Advanced Life Support

The topics reviewed by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force are grouped as follows: (1) causes and prevention, (2) airway and ventilation, (3) drugs and fluids given during cardiac arrest, (4) techniques and devices to monitor and assist the circulation, (5) periarrest arrhythmias, (6) cardiac arrest in special circumstances, (7) postresuscitation care, and (8) prognostication. Defibrillation topics are discussed in Part 3. The most important developments in advanced life support (ALS) since the last ILCOR review in 2000 include For many topics there were insufficient data with which to make firm treatment recommendations. The following interventions in particular need further research: Rescuers may be able to identify some noncardiac causes of arrest and tailor the sequence of attempted resuscitation. Most patients sustaining in-hospital cardiac arrest display signs of deterioration for several hours before the arrest. Early identification of these high-risk patients and the immediate arrival of …

Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.

To prospectively quantify the number of unrecognized missed out-of-hospital intubations by ground paramedics using emergency physician verification as the criterion standard for verification of endotracheal tube placement. The authors performed an observational, prospective study of consecutive intubated patients arriving by ground emergency medical services to two urban teaching hospitals. Endotracheal tube placement was verified by emergency physicians and evaluated by using a combination of direct visualization, esophageal detector device (EDD), colorimetric end-tidal carbon dioxide (ETCO(2)), and physical examination. During the six-month study period, 208 out-of-hospital intubations by ground paramedics were enrolled, which included 160 (76.9%) medical patients and 48 (23.1%) trauma patients. A total of 12 (5.8%) endotracheal tubes were incorrectly placed outside the trachea. This comprised ten (6.3%) medical patients and two (4.2%) trauma patients. Of the 12 misplaced endotracheal tubes, a verification device (ETCO(2) or EDD) was used in three cases (25%) and not used in nine cases (75%). The rate of unrecognized, misplaced out-of-hospital intubations in this urban, midwestern setting was 5.8%. This is more consistent with results of prior out-of-hospital studies that used field verification and is discordant with the only other study to exclusively use emergency physician verification performed on arrival to the emergency department.

Acute endotracheal tube occlusion caused by use of an esophageal detector device: Report of a case and a discussion of its utility

An experienced intensivist performed an emergency endotracheal intubation on a 72-year-old woman without difficulty. The vocal cords were visualized during the intubation. An esophageal detector device was used to confirm correct airway placement. After aspiration of the device, it was impossible to easily ventilate the patient. The endotracheal tube was removed and found to be occluded by a mucus plug. It is postulated that aspiration of the syringe on the esophageal detector device suctioned the mucus plug from the bronchial tree into the endotracheal tube and precluded ventilation of the airway. This complication has not been previously reported. The utility and possible hazards of the esophageal detector device are discussed.

Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.

To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. The authors conducted a prospective, observational analysis of out-of-hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out-of-hospital EIs using auscultation, direct laryngoscopy, infrared CO(2) detectors, esophageal detector devices, and chest x-ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. A total of 167 out-of-hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p < 0.05) than intermediate-level providers serving areas that are more rural. The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out-of-hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

Unrecognized Misplacement of Endotracheal Tubes in a Mixed Urban to Rural Emergency Medical Services Setting

Abstract Objective: To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. Methods: The authors conducted a prospective, observational analysis of out‐of‐hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out‐of‐hospital EIs using auscultation, direct laryngoscopy, infrared CO 2 detectors, esophageal detector devices, and chest x‐ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. Results: A total of 167 out‐of‐hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p &lt; 0.05) than intermediate‐level providers serving areas that are more rural. Conclusions: The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out‐of‐hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

The self-inflating bulb as an esophageal detector device in children weighing more than twenty kilograms: A comparison of two techniques

Study objectives: We confirm the ability of the self-inflating bulb to indicate endotracheal tube position in children and determine which method of bulb compression is more accurate. Methods: This single-blind, prospective, single cohort, repeated measures comparison of the on-deflate and the off-deflate methods of bulb compression was conducted in the operating room of a children's hospital. Seventy-five patients weighing more than 20 kg were enrolled. All patients had an endotracheal tube placed in both the trachea and the esophagus, 5 mL/kg of air was insufflated into the stomach, and 4 measurements were obtained on each patient. The bulb was either applied to the endotracheal tube and then compressed (on-deflate method), or compressed before its attachment to the endotracheal tube (off-deflate method). The order in which the methods were utilized was determined by a computer-generated permuted block randomization scheme. The blinded assessor told the anesthesiologist when to start and stop the clock after each intervention. Five seconds was used as the cut-off time for which the clock was stopped. If the bulb reexpanded within 5 seconds, then the tube was considered to be in the trachea; if it did not reexpand, then this was considered to be an esophageal intubation. Results: The mean patient age was 11 years. The on-deflate method had a sensitivity of 99% and a specificity of 92% for detecting tracheal intubations. The off-deflate method had a sensitivity of 99% and a specificity of 100% (95% confidence interval [CI] for the difference between methods: sensitivity −6 to 6, specificity −14 to 0.4). The inaccuracy rate for the off-deflate method was 1%, whereas the inaccuracy rate for the on-deflate method was 5% (Δ4; 95% CI 0.2 to 9). Conclusion: The self-inflating bulb is a reliable method of detecting endotracheal tube position in children. Furthermore, the off-deflate method may be more reliable and accurate than the on-deflate method when used in children weighing more than 20 kg. [Ann Emerg Med. 2003;41:623-629.]