Tube Position Research Articles

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

Numerical study of oscillation characteristics in T-shaped cryogenic helium tube

Thermoacoustic oscillations generally exist in combustion devices and cryogenic systems, causing system instability and other problems. The actual cryogenic system has complex pipe connections, however, there are few studies on the thermoacoustic oscillation of complex structures, which brings challenges to suppressing thermoacoustic instability. Therefore, this study focuses on the T-shaped helium tube existing in the actual cryogenic system and explores the oscillation characteristics of the complex cryogenic thermoacoustic system. With the change of branch position and length, mode transition phenomenon appears. We obtained the effects of the branch position and length on the amplitude and frequency of each mode and found that the self-excited oscillation in the T-shaped tube could be suppressed to some extent by choosing the proper length and position of the branch tube. Further research found that the first mode of the oscillating pressure in the main and branch tube was in-phase synchronized, and the second mode was antiphase synchronized. By linking the flow direction with the oscillation mode, it is found that the first mode corresponds to the first flow direction, and the second mode corresponds to the second or third flow direction. The finding is valuable for understanding thermoacoustic oscillations in T-tubes and provides a reference for controlling the self-excited oscillation of complex cryogenic systems.

A survey investigating postero-anterior chest X-ray clinical technique amongst radiographers and assistant practitioners in the UK: An extended pilot study

IntroductionWhilst many technical factors for the postero-anterior (PA) chest projection are well-researched and standardised, anecdotal evidence suggests a discrepancy regarding positioning of the X-ray tube; some radiographers using a horizontal tube, and others apply an angle. Currently there is a lack of published evidence supporting the benefits of either technique. MethodsFollowing University ethical approval, an invitation e-mail containing a link to a short questionnaire and participant information sheet was sent to radiographers and assistant practitioners in Liverpool and the surrounding areas, via professional networks/research team contacts. Questions related to length of experience, highest qualification and reasoned choice of horizontal versus angled tube preference in Computed Radiography (CR) and Digital Radiography (DR) rooms. The survey was open for nine weeks, with reminders at five and eight weeks. ResultsThere were 63 respondents. Both techniques were commonplace, with a non-statistically significant preference (p = 0.439) for a horizontal tube in both DR rooms (59%, n = 37) and CR rooms (52%, n = 30). Angled technique was employed by 41% (n = 26) of participants in DR rooms and 48% (n = 28) in CR rooms. Many participants indicated ‘taught’, or ‘protocol’, influenced their approach (46% [n = 29] in DR, 38% [n = 22] in CR). 35% (n = 10) of participants using caudal angulation, identified dose optimisation as the rationale in both CR and DR rooms. Most specifically noted reduced dose to the thyroid (69% [n = 11] in CR, 73% [n = 11] in DR). ConclusionsThere is evidence of variation in practice regarding horizontal versus an angled X-ray tube but no consistent rationale for either choice. Implications for practiceThere is a need to standardise tube positioning in PA chest radiography in line with future empirical research into the dose-optimisation implications of tube angulation.

Use of point-of-care ultrasound and serial FAST as a monitoring tool for the removal of an ectopic chest tube in liver

Common complications of chest tube insertion are lung laceration, chest wall bleeding, improper tube positioning, and subcutaneous emphysema. However, a penetrating injury of the upper abdominal organs due to chest tube malposition is rare. A 33-year-old suffered multiple injuries in a road traffic accident. Due to the respiratory distress caused by right-sided hemothorax, an intercostal chest drain (ICD) was inserted, which drained 500 ml of venous blood, followed by hemodynamic instability. The post-procedural chest radiograph revealed a lower chest tube position within the liver shadow. As the patient was hemodynamically stable, it was decided to delay the removal of the ectopic ICD, and the patient was kept under close monitoring. After 7 days, ICD removal was done under ultrasound guidance, and a post-procedural serial-focused assessment with sonography for trauma (FAST) was done. Hepatic injury secondary to chest tube insertion is rare, and its management is not standardised. Point-of-care ultrasound has not been used before for the removal of an ectopic ICD. We managed the case conservatively because of the stable hemodynamic situation of the patient and to avoid invasive surgery as possible. Point-of-care ultrasound can be a valuable tool in these conditions where other imaging modalities such as CT are not available and help avoid surgery.

The accuracy of intensive care nurses' interpretation of chest radiographs to recognise misplacement of endotracheal and nasogastric tubes after a single training session and comparison with residents' interpretation

BackgroundMisplacements of endotracheal and nasogastric tubes are frequent encounters in critically ill patients. ObjectivesThe purpose of this study was to assess the effectiveness of a single standardised training session on the ability of intensive care registered nurses (RNs) to recognise the misplacement of endotracheal and nasogastric tubes on bedside chest radiographs of patients in intensive care units (ICUs). MethodsIn eight French ICUs, RNs received a 110-min standardised teaching on the position of endotracheal and nasogastric tubes on chest radiographs. Their knowledge was evaluated within the subsequent weeks. For 20 chest radiographs, each with an endotracheal and nasogastric tube, RNs had to indicate whether each tube was in the proper or incorrect position. Training success was defined as >90% for the lower bound of the 95% confidence interval (95% CI) of the mean correct response rate (CRR). Residents of the participating ICUs underwent the same evaluation (without prior specific training). ResultsIn total, 181 RNs were trained and evaluated and 110 residents were evaluated. The global mean CRR for RNs was 84.6% (95% CI: 83.3–85.9), significantly higher than for residents (81.4% [95% CI: 79.7–83.2]) (P < 0.0001). The mean CRR for RNs and residents was 95.9% (93.9–98.0) and 97.0% (94.7–99.3) for misplaced nasogastric tubes (P = 0.54), 86.8% (85.2–88.5) and 82.6% (79.4–85.7) (P = 0.07) for nasogastric tubes in the correct position, 86.6% (83.8–89.3) and 62.7% (57.9–67.5) for misplaced endotracheal tubes (P < 0.0001), and 79.1% (76.6–81.6) and 84.7% (82.1–87.2) for endotracheal tubes in the correct position (P = 0.01), respectively. ConclusionsThe ability of trained RNs to detect tube misplacement did not reach the predetermined arbitrary level, indicating training success. Their mean CRR was higher than that for residents and was considered satisfactory for detecting misplaced nasogastric tubes. This finding is encouraging but insufficient to ensure patient safety. Transferring responsibility for reading radiographs to detect the misplacement of endotracheal tubes to intensive care RNs will need a more advanced or more in-depth teaching method.

Diagnostic Accuracy of Auscultation During General Anesthesia by Taking Fiberoptic Bronchoscopy as Gold Standard

Objective: To evaluate the diagnostic accuracy of auscultation in the detection of inappropriate positioning of endotracheal tube, in patients undergoing elective surgeries, by taking fiberoptic bronchoscopy as gold standard. Study design: cross sectional study Place and duration: Department of anesthesia, Nishtar Hospital, Multan Methodology: A total of 205 patients admitted in general surgery ward were included in the study. The pre-operative assessment was done one day before surgery. The level of difficulty of intubation was assessed during pre-operative assessment. SPSS version 23 was used for data analysis. Tests of significance chi square and t-test were applied. P-value &lt; 0.05 was taken as statistically significant. Results: Therefore, the estimated sensitivity was 72.03%. The estimated specificity was 65.6%. Positive predictive value was 73.9% and negative predictive value was 63.3%. Two hundred and five patients were included in this study of both genders. Gender distribution revealed as n=144 (70.2%) males and n=61 (29.8%) females. The mean age of the patients was 38.92±10.61years. ASA status I and II observed as n=121 (59.0%) and n=84 (41.0%), respectively. Mallampati grading I and II observed as n=127 (62.0%) and n=78 (38.0%), respectively. Laryngoscopy grading I and II observed as n=135 (65.9%) and n=70 (34.1%), respectively. Practical Implication: The main objective of this study was to evaluate the relative diagnostic accuracy of auscultation during GA. Therefore, we evaluated each technique's sensitivity, specificity, (PPV), (NPV) and overall accuracy in detecting incorrect endotracheal tube positioning. Conclusion: The five point auscultation technique is a reliable method of confirmation of endotracheal intubation, as verified by flexible fiberoptic bronchoscope. Keywords: Auscultation, Fiberoptic bronchoscopy, General analgesia, Diagnostic accuracy, sensitivity.

The Role of Thoracic Ultrasound for Diagnosis of Diseases of the Chest Wall, the Mediastinum, and the Diaphragm—Narrative Review and Pictorial Essay

The diagnostic capabilities of ultrasound extend far beyond the evaluation of the pleural space and lungs. Sonographic evaluation of the chest wall is a classic extension of the clinical examination of visible, palpable, or dolent findings. Unclear mass lesions of the chest wall can be differentiated accurately and with low risk by additional techniques such as color Doppler imaging, contrast-enhanced ultrasound, and, in particular, ultrasound-guided biopsy. For imaging of mediastinal pathologies, ultrasound has only a complementary function but is valuable for guidance of percutaneous biopsies of malignant masses. In emergency medicine, ultrasound can verify and support correct positioning of endotracheal tubes. Diaphragmatic ultrasound benefits from the real-time nature of sonographic imaging and is becoming increasingly important for the assessment of diaphragmatic function in long-term ventilated patients. The clinical role of thoracic ultrasound is reviewed in a combination of narrative review and pictorial essay.

Usefulness of ultrasound in confirming the correct placement of Ryle's tube compared to the traditional method of auscultation in normal versus overweight and obese patients.

Auscultation to verify Ryle's tube position is difficult in obese patients. We compared the usefulness of ultrasonography (USG) versus auscultation in confirming the correct Ryle's tube placement in normal versus overweight or obese patients, time taken for confirmation, and incidence of reinsertion. A prospective, observational study was carried out on 80 patients. Patients with a body mass index (BMI)>25 kg/m2 formed group O and those with BMI <25 kg/m2 constituted group N. After Ryle's tube insertion correct placement was first confirmed by auscultation. The presence of a gurgling sound over the epigastrium was graded (definite/doubtful/absent). During USG evaluation, if Ryle's tube was not visualized at the subxiphoid region, 20mL of air was injected, looking for dynamic fogging in the stomach. If auscultation yielded doubtful or absent results and USG also failed to confirm, Ryle's tube was repositioned and confirmed. Group O had a significantly higher BMI. Auscultation time and the time taken for USG confirmation were significantly longer in group O. The percentage of patients with definite auscultatory signs was significantly higher in group N. Significantly higher number of patients in group O had doubtful/absent auscultatory signs. Ryle's tube and fogging visualization with USG and the requirement of reinsertion were comparable in both groups. The percentage of patients with definite auscultatory confirmation and definite USG confirmation were comparable in group N. However, in group O, significantly lesser patients had definite auscultatory confirmation compared to definite USG signs. Confirmation of the correct placement of Ryle's tube using ultrasound is easier than auscultation in overweight and obese patients. In normal patients, both techniques are equally useful.

A new formula based on height for determining endotracheal intubation depth in pediatrics: A prospective study

Study objectiveThe main objective was to devise an endotracheal intubation formula based on pediatric patients' strongly correlated growth parameters. The secondary objective was to compare the accuracy of the new formula to the age-based formula from Advanced Pediatric Life Support Course (APLS formula) and the middle finger length-based formula (MFL-based formula). DesignA prospective, observational study. SettingOperation. Patients111 subjects age 4–12 years old undergoing elective surgeries with general orotracheal anesthesia. Interventions and measurementsGrowth parameters, including age, gender, height, weight, BMI, middle finger length, nasal-tragus length, and sternum length, were measured before surgeries. Tracheal length and the optimal endotracheal intubation depth (D) were measured and calculated by Disposcope. Regression analysis were used to establish a new formula for predicting the intubation depth. A self-controlled paired design was used to compare the accuracy of the intubation depth between the new formula, APLS formula, and MFL-based formula. Main resultsHeight (R = 0.897, P < 0.001) was strongly correlated to tracheal length and the endotracheal intubation depth in pediatric patients. New formulae basing on height were established, including new formula 1: D (cm) = 4 + 0.1 × Height (cm) and new formula 2: D (cm) = 3 + 0.1 × Height (cm). Via Bland-Altman analysis, the mean differences for new formula 1, new formula 2, APLS formula and MFL-based formula were − 0.354 cm (95% LOA, −1.289 to 1.998 cm), 1.354 cm (95% LOA, −0.289 to 2.998 cm), 1.154 cm (95% LOA, −1.002 to 3.311 cm), −0.619 cm (95% LOA, −2.960 to 1.723 cm), respectively. The rate of optimal intubation for new formula 1 (84.69%) was higher than for new formula 2 (55.86%), APLS formula (61.26%), and MFL-based formula. (69.37%). ConclusionsThe prediction accuracy for intubation depth of the new formula 1 was higher than the other formulae. The new formula based on height: D (cm) = 4 + 0.1 × Height (cm) was preferable to APLS formula and MFL-based formula with a high incidence of appropriate endotracheal tube position.

Optimization of Liquid−Liquid Mixing in a Novel Mixer Based on Hybrid SVR-DE Model

To solve the problem of evenly mixing flocculant and sewage, a new type of two-chamber mechanical pipe mixer was numerically calculated and its working principle was studied by means of the internal flow field. The single factor numerical simulation and analysis of some of the structural parameters in the mixer were carried out to determine the influence of different parameters on the results. Latin hypercube sampling was used to design 100 sets of test tables for the four variables of the branch pipe diameter, sewage flow rate, the installation height of the impeller, and the angle of the deflector. The results were optimized using the SVR-DE algorithm. After optimization, the variation coefficient of export flocculant mixing uniformity was 16.02%, which was increased by 74.94% compared with the initial 63.921%. The power consumption of the impeller was reduced by 8.30%. The concentration curves of the flocculant at different positions of the outlet tube could quickly converge to the target value.

Why the Lung Doesn’t Expand After Chest Tube Insertion?: Learning from Errors

Chest tube insertion is one of the common and critical procedures in emergency room. The most common tool for chest tube position confirmation is chest x-ray. The aim of this case report is to explain one of pitfalls of this tool in confirmation of chest tube position. The patient was a 36-year-old man who had been transferred to ED by EMS due to blunt chest trauma in a motor vehicle collision. After detecting pneumothorax in chest CT scan, chest tube has been inserted and chest x ray has been done for chest tube`s place confirmation. X-ray ascertains that the tube is in the right place but lung does not expand and dyspnea does not improve completely. In chest CT scan which will be done after 2 days, it reveals that chest tube was in subcutaneous tissue. Although chest x-ray is a useful modality to confirm chest tube placement, chest tube function can define important information and imaging should be interpreted beside clinical coarse. It should be noted that in the case of current report, the physical examination is used.

Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times.

Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.

Effects of gas inlet orientation on discharge characteristics of coaxial dual-channel cross-field atmospheric plasma jet

In this paper, the effect of the gas inlet orientation on the discharge characteristics of the coaxial dual-channel cross-field plasma jet is investigated. A working gas helium is separately flowed into the annular space between the hollow needle tube and the quartz tube (called Q-Jet), as well as the hollow needle tube (called N-Jet). With the same discharge parameters, the results show that the radial and axial dimensions of Q-Jet plasma jet are larger than that of N-Jet. Compared with the latter, the discharge current amplitude of the former increases by about 3.8-fold, the net charge transferred increases by about 8.8-fold, and the variety and density of reactive species produced are remarkably increased. For Q-Jet, the 706-nm spectral band is distributed inside and outside the quartz tube, while the 391-nm spectral band is mainly distributed outside the quartz tube, and the plasma jet forms a conical luminous pattern in the quartz tube during the positive half cycle of the voltage, due to the influence of helium viscosity. For N-Jet, 706- and 391-nm spectral bands are only just distributed in the axis of the quartz tube, and the charges left by the first discharge in the axial position of the quartz tube remarkably amplify the intensity of the second discharge in the positive half cycle.

An Artificial Neural Network for Nasogastric Tube Position Decision Support.

To develop and validate a deep learning model for detection of nasogastric tube (NGT) malposition on chest radiographs and assess model impact as a clinical decision support tool for junior physicians to help determine whether feeding can be safely performed in patients (feed/do not feed). A neural network ensemble was pretrained on 1 132 142 retrospectively collected (June 2007-August 2019) frontal chest radiographs and further fine-tuned on 7081 chest radiographs labeled by three radiologists. Clinical relevance was assessed on an independent set of 335 images. Five junior emergency medicine physicians assessed chest radiographs and made feed/do not feed decisions without and with artificial intelligence (AI)-generated NGT malposition probabilities placed above chest radiographs. Decisions from the radiologists served as ground truths. Model performance was evaluated using receiver operating characteristic analysis. Agreement between junior physician and radiologist decision was determined using the Cohen κ coefficient. In the testing set, the ensemble achieved area under the receiver operating characteristic curve values of 0.82 (95% CI: 0.78, 0.86), 0.77 (95% CI: 0.71, 0.83), and 0.98 (95% CI: 0.96, 1.00) for satisfactory, malpositioned, and bronchial positions, respectively. In the clinical evaluation set, mean interreader agreement for feed/do not feed decisions among junior physicians was 0.65 ± 0.03 (SD) and 0.77 ± 0.13 without and with AI support, respectively. Mean agreement between junior physicians and radiologists was 0.53 ± 0.05 (unaided) and 0.65 ± 0.09 (AI-aided). A simple classifier for NGT malposition may help junior physicians determine the safety of feeding in patients with NGTs.Keywords: Neural Networks, Feature Detection, Supervised Learning, Machine Learning Supplemental material is available for this article. Published under a CC BY 4.0 license.

Numerical simulation of heat recovery from asphalt pavement in Finnish climate conditions

A 3-dimensional mathematical model of asphalt pavement system was developed, based on the fundamental energy balance, to calculate temperatures beneath asphalt surface using hourly measured solar radiation, air temperature and wind velocity data. The modelling was conducted to predict the heat retention under the asphalt surface to seek an optimum position of pipe tubing to maximise the heat extraction considering the Nordic winter conditions for future infrastructure projects. The model results show good agreement with the experimental results conducted in a span of three months (June–Sept) notwithstanding the simplification of the model i.e. thermal properties unaffected by changing moisture content, perfect contact between different layers and homogeneous and isotropic thermal properties of materials (asphalt, sand and gravel). The findings indicated that the positioning of the heat extraction tubes under the asphalt layer will be dictated by the application. For heat extraction, pipes closer to the surface are ideal for maximal heat absorption during summer, however, in winter the outer temperature may effect properties the pipes. Parameters including pipe diameter, positioning of the pipes and flow rate were analysed. Temperature increase of up to 10°C gain was observed for piping closer to the asphalt layer and 6°C for pipes position at deeper from the asphalt layer. This model could be used in future to optimise critical variables for successful implementation of asphalt heating concepts.

Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate thepractices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the teamand a senior resident(37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscopefor intubation (62.8%), whereas video laryngoscopewas used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

Image augmentation and automated measurement of endotracheal-tube-to-carina distance on chest radiographs in intensive care unit using a deep learning model with external validation

BackgroundChest radiographs are routinely performed in intensive care unit (ICU) to confirm the correct position of an endotracheal tube (ETT) relative to the carina. However, their interpretation is often challenging and requires substantial time and expertise. The aim of this study was to propose an externally validated deep learning model with uncertainty quantification and image segmentation for the automated assessment of ETT placement on ICU chest radiographs.MethodsThe CarinaNet model was constructed by applying transfer learning to the RetinaNet model using an internal dataset of ICU chest radiographs. The accuracy of the model in predicting the position of the ETT tip and carina was externally validated using a dataset of 200 images extracted from the MIMIC-CXR database. Uncertainty quantification was performed using the level of confidence in the ETT–carina distance prediction. Segmentation of the ETT was carried out using edge detection and pixel clustering.ResultsThe interrater agreement was 0.18 cm for the ETT tip position, 0.58 cm for the carina position, and 0.60 cm for the ETT–carina distance. The mean absolute error of the model on the external test set was 0.51 cm for the ETT tip position prediction, 0.61 cm for the carina position prediction, and 0.89 cm for the ETT–carina distance prediction. The assessment of ETT placement was improved by complementing the human interpretation of chest radiographs with the CarinaNet model.ConclusionsThe CarinaNet model is an efficient and generalizable deep learning algorithm for the automated assessment of ETT placement on ICU chest radiographs. Uncertainty quantification can bring the attention of intensivists to chest radiographs that require an experienced human interpretation. Image segmentation provides intensivists with chest radiographs that are quickly interpretable and allows them to immediately assess the validity of model predictions. The CarinaNet model is ready to be evaluated in clinical studies.Graphical

Simulation-based Ultrasound Curriculum for Novice Clinicians to Assess Neonatal Endotracheal Tube Position.

To evaluate the efficacy of a simulation-based mastery curriculum to train clinicians with limited-to-no sonography experience how to use ultrasound (US) to assess neonatal endotracheal tube (ETT) positioning. In a single-centered, prospective, educational study, 29 neonatology clinicians participated in a simulation-based mastery curriculum composed of a didactic lecture, followed by a one-on-one simulation session using a newly designed, three-dimensional (3D) printed US phantom model of the neonatal trachea and aorta. After mastery training, clinicians were evaluated with a performance checklist on their skills obtaining US images and assessing ETT positioning in the US phantom model. They also completed pre- and postcurriculum knowledge assessment tests and self-assessment surveys. The data were analyzed using Wilcoxon signed rank tests and repeated measures analysis of variance. The mean checklist score improved significantly during three attempts (mean difference: 2.6552; 95% confidence interval [CI]: 2.2578-3.0525; P < 0.0001). The mean time to perform US decreased significantly from the first to third attempt (mean difference: -1.8276 min; 95% CI: -3.3391 to - 0.3161; P = 0.0196). In addition, there was a significant improvement in median knowledge assessment scores (50% vs. 80%; P < 0.0001) and survey ratings on knowledge and self-efficacy (P < 0.0001). Clinicians with limited-to-no sonography experience demonstrated improved knowledge and skill acquisition in using US to assess ETT positioning through simulation-based mastery training. The use of 3D modeling enhances simulation experiences and optimizes the quality of training during limited opportunities to achieve procedural competency in a controlled environment before further application into the clinical setting.

Evaluation of end tidal capnography and upper airway ultrasonography for confirmation of endotracheal tube placement in adult patients undergoing elective surgery: Capnography versus ultrasonography for endotracheal tube placement

Introduction: Capnography has been considered the gold standard method for confirmation of endotracheal tube placement. The current cross-sectional observational study was undertaken to compare upper airway ultrasonography and capnography for confirmation of endotracheal tube placement in patients undergoing elective surgery. Methods: 75 adult patients (18-60 years of age) belonging to ASA physical status I or II, scheduled for elective surgery under general anaesthesia requiring oral endotracheal intubation were enrolled for the study. After intubation, proper placement of endotracheal tube was confirmed by chest auscultation, end tidal capnography and upper airway ultrasonography simultaneously. Sensitivity, specificity, positive and negative predictive values of both capnography and ultrasonography were computed. Results: Using capnography, the position of endotracheal tube was found to be in the trachea in 72 patients (96%) and not in the trachea in 3 patients (4%). Ultrasonography was able to detect all 3 esophageal intubations but failed to confirm 2 endotracheal intubations. Capnography had sensitivity, specificity, positive and negative predictive values all at 100%. Ultrasonography had sensitivity of 97.22%, specificity of 100%, positive predictive value of 100% and negative predictive value of 60%. The kappa value was 0.737 which indicates a good correlation between capnography and upper airway ultrasound. Conclusion: Ultrasonography provides a real time dynamic visualization of the endotracheal tube. This study was able to demonstrate that ultrasonography is an acceptable, faster and safer method for confirming endotracheal tube placement. However, further studies are recommended to determine the best approach for emergency situations, patients with a difficult airway, and in critical care settings.

Comparison Between Ultrasonography and Capnography in the Assessment of Endotracheal Tube Placement after General Anesthesia

Background: Verification of endotracheal tube placement is of vital importance and can prove rapidly fatal.Because the placement of unrecognized esophageal tubes is so obviously detrimental, several instruments andtechniques have been investigated to get rid of such fatal complications. While there are numerous methods anddevices utilized for verifying endotracheal tube placement, none have been shown to be completely reliable. Inthe present study, we compared the upper airway ultrasound with capnography so as to assess endotracheal tubeplacements rapidly and accurately following general anesthesia (GA).Aim of the study: The aim is to examine how much fast and accurate the ultrasound in comparison withcapnography for assessing the endotracheal tube placement after general anesthesia.Patients and methods: This prospective cross-sectional study was conducted on (100) patients requiring trachealintubation under general anesthesia by using ultrasonography for confirming the endotracheal tube positioncompared to capnography.Results: Significant differences were found in the meantime for the group (A) between ultrasound (US) andcapnography. But in the group (B), there was no significant difference between means of time for confirmation byU/S and capnography. A P-value less than (0.05) was considered significant.Conclusion: In confirming the position of the tracheal tube, the real-time US was shown to be similar tocapnography in accuracy.