Tracheal Ultrasonography Research Articles

The Effect of the Ultrasonography Measurement Method and the Conventional Measurement Method Used in Endotracheal Tube Size Selection in the Pediatric Patient Group on Postextubation Complications and Patient Recovery.

In this study, we aimed to compare the cuffed intubation tube selected with the Cole formula and tracheal ultrasonography (USG) measurement method regarding postextubation complications in providing airway patency and determine its effects on patient recovery. Between 01 July 2022 and 30 June 2023, American Society of Anesthesiologists (ASA) risk group I-III, 4-6-year-old patients who underwent pediatric orthodontic surgery (multiple tooth extraction) were included in the study. Data of age, gender, weight, ASA risk group, history, Cole formula, USG measurement results used in the endotracheal tube (ETT) selection (one of the two whichever application was used), fasting time, intubation success, operation time, 30th-minute modified Aldrete recovery score (MASS), and postoperative complications due to intubation (within the first postoperative hour) were analyzed retrospectively. The patients were divided into two groups according to the method used by the anesthesiologists in selecting the ETT at the beginning of the operation. The group that used Cole formula management was named I, while the group that used the USG measurement method was called II. Intubation-related complication data of the patients in the first 1 hour postoperatively and MASS values at the 30th minute were compared between the groups. In this study, 52.5% of the cases were male (n=42), 47.5% were female (n=38), the mean age was 4.84±0.84 years, and the mean body weight was 22.56±7.58 kilogram. There was no statistically significant difference between the groups regarding age, gender, body weight, ASA score, operation time, and period without oral consumption. ETT diameter measurement values according to groups were 4.73±0.46 mm in Group I and 4.41±0.61 mm in Group II. Postoperative 30th-minute MASS values were median 7 in Group I and median 8 in Group II (p<.001). MASS values were significantly higher in the Group II patient group. Intubation-related complications (postoperative cough, stridor, laryngospasm, tachypnea, wheezing, dysphonia) were observed in Group I with a rate of 40% within the first postoperative hour, while complications were marked with a rate of 17.5% in Group II (p=0.026). Complications in group II were significantly lower. In the pediatric age group, especially under the age of 6, trachea measurement with USG and ETT selection is an effective, safe, and noninvasive method compared to other conventional methods. ETT size selection with USG accelerates postoperative patient recovery and reduces the risk of intubation-related complications. In addition, inflating the tube cuff under USG guidance can prevent cuff-related complications.

Comparison of lung ultrasound technique versus clinical method to evaluate the accuracy of size and placement of left endobronchial double lumen tube in patients undergoing elective thoracic surgery: a prospective observational study.

Anthropometric measurements like height and gender have been frequently found to be inaccurate in prediction of size of double lumen tube (DLT). A tracheal ultrasonography (TUS) is a technique that can be used to predict the size of DLT and its correct placement for lung isolation. We aim to check the accuracy of ultrasound over clinical methods. This prospective study included 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) with DLT. The groups were assessed for the size of DLT by either anthropometric measurement using height and gender (Group C) or ultrasound method (Group U). Further, the accuracy of placement of DLT was assessed through, either lung auscultation in group C or various ultrasonographic and ventilatory parameters such as lung isolation in the first attempt (lung sliding and lung pulse sign), oxygenation status and peak airway pressure, in group U. Surgeon satisfaction score was also compared in both the groups. The accuracy of predicted DLT size between Group C and Group U was statistically significant (p=0.044). In Group C, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group U, the mismatch was only 32.4%. The accuracy of DLT placement through group C was 41% as compared to 79% in Group U. Surgeon satisfaction score was also significantly higher in Group U as compared to Group C (p=0.0028). Thus, our study suggests that tracheal and chest ultrasonography for DLT size selection and placement for lung isolation is superior to clinical methods.

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

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

Abstract No. : ABS0814: Comparison of lung ultrasound technique versus clinical method to evaluate the accuracy of positioning of left endobronchial double lumen tube in patients undergoing elective thoracic surgery- a prospective observational study

Background & Aims:Clinical methods like height and gender were found to be inaccurate in predicting the size of double-lumen tube (DLT).Tracheal ultrasonography (TUS) reliably predicts the size of DLT by measuring tracheal diameter. The aim wasto check theaccuracy of ultrasound over clinical methods.Methods:This study was conducted on 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) withDLT. The subjects were divided into two groups depending on the prediction of size of DLT by either clinical (Group1) orultrasound method. (Group 2). The transducer was placed perpendicular to skin over cricoid cartilage to measure the transversediameter of the column of air in the cricoid cartilage which denoted the size of the DLT. The primary objective of the study was to assess the accuracy in prediction of size and placement of DLT through various parameters in both clinical andultrasound groups.Results:The accuracy of predicted DLT size between the Group U and Group C was found to be statistically significant (p=0.044). In Group 1, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group 2, the mismatch was only 32.4%. The accuracy of placement of DLT in the first attempt suggested by adequate lung isolation was also significantly higher (p=0.028) in the ultrasound group compared to the clinical group.Conclusion:The size of DLT can be predicted by using clinical parameters but have low accuracy. In our study, the size of DLT was calculated by measuring tracheal diameter using TUS, which significantly improved the selection of appropriate DLT size, avoiding complications.Actual DLT usedGroup 1Group 2Z test No.%No.%Same as predicted1544.02367.6Z=-2.01, P=0.044*Higher that predicted823.5514.7Lower than predicted1132.5617.6Total34100.034100.0

Application of bedside real-time tracheal ultrasonography for confirmation of emergency endotracheal intubation in patients in the intensive care unit.

ObjectiveCritically ill patients often require emergency endotracheal intubation and mechanical ventilation. When esophageal intubation is not confirmed early, treatment may be delayed, even for life-threatening conditions. We examined the accuracy of bedside real-time airway ultrasonography in confirming the endotracheal tube (ETT) position during emergency endotracheal intubation in patients in the intensive care unit (ICU).MethodsThis single-center prospective observational study included 118 patients who underwent urgent endotracheal intubation in the ICU of Taizhou Hospital of Integrated Traditional Chinese and Western Medicine. Tracheal ultrasonography was used to confirm the ETT position during endotracheal intubation, after which fiberoptic bronchoscopy was performed. The accuracy of bedside real-time tracheal ultrasonography in determining the ETT position was examined.ResultsTwelve (10.2%) patients underwent endotracheal intubation. The kappa value was 0.844, indicating perfect consistency between tracheal ultrasonography and fiberoptic bronchoscopy in identifying esophageal intubation. The sensitivity, specificity, and positive and negative predictive values of tracheal ultrasonography in determining the ETT position were 75.0%, 100%, 100%, and 97.2%, respectively.ConclusionsBedside real-time tracheal ultrasonography accurately assesses the ETT position in the ICU and can identify the ETT position during intubation. These findings have important clinical applications and are of great significance for treatment of ICU patients.

The role of tracheal ultrasonography in confirming endotracheal tube placement in respiratory intensive-care unit patients

The role of tracheal ultrasonography in confirming endotracheal tube placement in respiratory intensive-care unit patients

Real-time tracheal ultrasonography for confirming endotracheal tube placement

ObjectiveTo evaluate the accuracy of tracheal ultrasonography for confirming the endotracheal tube placement during patients’ intubation.Patients and methodsThe current study was a prospective, randomized study performed at the ICU of Al-Hussein Hospital, Cairo. Intubated for respiratory failure, cardiac arrest or other medical causes were included in the current study. Real-time tracheal ultrasonography was conducted during intubation with the ultrasound probe placed transversely over the trachea above the suprasternal notch for confirming the tube position, either tracheal or esophageal. The standard method for confirming endotracheal tube placement include clinical evaluation and rapid bronchoscopic confirmation. The main outcomes were the degree of accuracy and timeliness of tracheal ultrasound in confirming endotracheal tube placement.ResultsForty patients eligible for endotracheal intubation were randomized in the current study and only four (10%) patients had confirmed esophageal intubations. Our results concluded that tracheal ultrasound had a diagnostic accuracy of 97.5% in the detection of endotracheal tube site. The sensitivity was 97.2%, while the specificity was 100%. Tracheal ultrasound had a positive predictive value of 100%, while the negative predictive value was 80%. The total operating time of ultrasonography was significantly lower than that of bronchoscopy.ConclusionReal-time ultrasound of the trachea is an accurate, feasible, and fast method in confirming endotracheal tube placement.

Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study

ObjectivesConfirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber-optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time-consuming, and not always practical. Inexpensive endoscopic USB-cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB-camera. MethodsThis study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB-endoscopy. We have prepared a randomized intubation list (n=96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB-endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2cm wide ostium on the proximal trachea. ResultsIn this study, all intubations (n=96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB-camera. Both the sensitivity and specificity of TUS and USB-endoscopy for the CoETP were 100.0%. ConclusionThe perfect accuracy of TUS and USB-endoscopy, have placed those techniques in a unique position as an alternative in resource-poor situations.

Screening Characteristics of Bedside Ultrasonography in Confirming Endotracheal Tube Placement; a Diagnostic Accuracy Study.

Confirmation of proper endotracheal tube placement is one of the most important and lifesaving issues of tracheal intubation. The present study was aimed to evaluate the accuracy of tracheal ultrasonography by emergency residents in this regard. This was a prospective, cross sectional study for evaluating the diagnostic accuracy of ultrasonography in endotracheal tube placement confirmation compared to a combination of 4 clinical confirmation methods of chest and epigastric auscultation, direct laryngoscopy, aspiration of the tube, and pulse oximetry (as reference test). 150 patients with the mean age of 58.52 ± 1.73 years were included (56.6% male). Sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio of tracheal ultrasonography in endotracheal tube confirmation were 96 (95% CI: 92-99), 88 (95% CI: 62-97), 98 (95% CI: 94-99), 78 (95% CI: 53-93), 64 (95% CI: 16-255), and 0.2 (95% CI: 0.1-0.6), respectively. The present study showed that tracheal ultrasonography by trained emergency medicine residents had excellent sensitivity (>90%) and good specificity (80-90) for confirming endotracheal tube placement. Therefore, it seems that ultrasonography is a proper screening tool in determining endotracheal tube placement.

Tracheal ultrasonography and ultrasonographic lung sliding for confirming endotracheal tube placement: Speed and Reliability

BackgroundIn this study we aimed to evaluate the success of ultrasonography (USG) for confirming the tube placement and timeliness by tracheal USG and ultrasonographic lung sliding in resuscitation and rapid sequence intubation. Materials and methodsThis study was a prospective, single-center, observational study conducted in the emergency department of a tertiary care hospital. Patients were prospectively enrolled in the study. Patients who went under emergency intubation because of respiratory failure, cardiac arrest or severe trauma included in the study. Patients with severe neck trauma, neck tumors, history of neck operation or tracheotomy and under 18years old were excluded from the study. ResultsA total of 115 patients included in the study. The mean age was 67.2±17.1 with age 16–95years old. Among 115 patients 30 were cardiac arrest patients other 85 patients were non-cardiac arrest patients intubated with rapid sequence intubation. The overall accuracy of the ultrasonography was 97.18% (95% CI, 90.19–99.66%), and the value of kappa was 0.869 (95% CI, 0.77–0.96), indicating a high degree of agreement between the ultrasonography and capnography. The ulrasonography took significantly less time than capnography in total. DiscussionUltrasonography achieved high sensitivity and specificity for confirming tube placement and results faster than end-tidal carbon dioxide. Ultrasonography is a good alternative for confirming the endotracheal tube placement. Future studies should examine the use of ultrasonography as a method for real-time assessment of endotracheal tube placement by emergency physicians with only basic ultrasonographic training.

Laryngo-tracheal ultrasonography to confirm correct endotracheal tube and laryngeal mask airway placement.

Waveform capnography was recommended as the most reliable method to confirm correct endotracheal tube or laryngeal mask airway placements. However, capnography may be unreliable during cardiopulmonary resuscitation and during low flow states. It may lead to an unnecessary removal of a well-placed endotracheal tube, re-intubation and interruption of chest compressions. Real-time upper airway (laryngo-tracheal) ultrasonography to confirm correct endotracheal tube placement was shown to be very useful in cadaveric models and during emergency intubation. Tracheal ultrasonography does not interrupt chest compressions and is not affected by low pulmonary flow or airway obstruction, but is limited by ultrasonography scattering and acoustic artifacts generated in air – mucosa interfaces. Sonographic upper airway assessment emerges as a rapid and easily available method to predict difficult intubation, to assess the laryngeal and hypopharyngeal size and visualize the position of the laryngeal mask airway in situ. This study demonstrates that the replacement of air with saline in endotracheal tube or laryngeal mask airway cuffs and the use of the contrast agents enables detection of cuffs in the airway. It also allows visualization of the surrounding structures or tissues as the ultrasound beam can be transmitted through the fluid – filled cuffs without being reflected from air – mucosal interfaces.

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children

ObjectiveWe evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. MethodsWe performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. ResultsForty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90–100%), a specificity of 96.4% (95% CI=87–100%), a PPV of 96.5% (95% CI=87–100%), a NPV of 98.8% (95% CI=89–100%), a positive likelihood ratio of 32 (95% CI=6–185), and a negative likelihood ratio of 0.015 (95% CI=0.004–0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0–15.0s). ConclusionsSonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

Ultrasonography for Proper Endotracheal Tube Placement Confirmation in Out-of-hospital Cardiac Arrest Patients: Two-center Experience

Background A secure airway and effective ventilation are key components of resuscitation. Real-time airway sonographic approaches could enhance physician confidence and decision-making in relation to tracheal tube placement. This study aims to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position in patients at two medical centers who have undergone cardiac arrest. Patients and methods We performed a prospective two-center observational study for adult patients with cardiac arrest from July 2012 to June 2013. Real-time tracheal ultrasonography was performed during the intubation. The endotracheal tube position was defined as endotracheal if single air-mucosa interface with comet-tail artefact was observed. Esophageal intubation was defined if a second air-mucosa interface appeared. The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during cardiopulmonary resuscitation. Results Among the 96 patients enrolled, 7 (7.3%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 98.9% [95% confidence interval (CI): 94.0–99.8%], 100% (95% CI: 61–100.0%), 100% (95% CI: 95.9–100.0%), and 85.7% (95% CI: 48.7–97.4%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1–43.0) and 0.0, respectively. Additionally, subgroup analysis was performed based on the hospital. However, no significant difference existed in the accuracy of tracheal ultrasonography and patient characteristics. Conclusion Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during cardiopulmonary resuscitation without the need for interruption of chest compression.

Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience

Among the 96 patients enrolled, 7 (7.3%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 98.9% (95% confidence interval [CI]: 94.0-99.8%), 100% (95% CI: 61-100.0%), 100% (95% CI: 95.9-100.0%) and 85.7% (95% CI: 48.7-97.4%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively.

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation

ObjectiveThis study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). MethodsWe performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air–mucosa (A–M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A–M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A–M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. ResultsAmong the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4–100%), 85.7% (95% CI: 42.0–99.2%), 98.8% (95% CI: 92.5–99.0%) and 100% (95% CI: 54.7–100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1–43.0) and 0.0, respectively. ConclusionsReal-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.

Ultrasonographic evaluation of tracheal collapse in dogs

Tracheal ultrasonography was performed to measure the width of the tracheal ring shadow and to assess the clinical relevance of these measurements for identifying tracheal collapse. The first tracheal ring width (FTRW) and thoracic inlet tracheal ring width (TITRW) were measured on both expiration and inspiration. The mean of the FTRW width (129 dogs) was greater in expiration (10.97 ± 1.02 mm, p = 0.001) than that in inspiration (9.86 ± 1.03 mm). For 51 normal dogs, the mean of the TITRW width was greater in expiration (9.05 ± 1.52 mm, p = 0.001) than in inspiration (8.02 ± 1.43 mm). For 78 tracheal collapse dogs, the mean of the TITRW width was greater in expiration (15.89 ± 1.01 mm, p = 0.001) than in inspiration (14.85 ± 1.17 mm). The TITRW/FTRW ratio of the normal dogs was higher (p = 0.001) in expiration (0.81 ± 0.09) than that in inspiration (0.79 ± 0.10). When compared between the normal and tracheal collapse dogs, the TITRW/FTRW ratio was also increased (p = 0.001) both in expiration (1.54 ± 0.09) and inspiration (1.47 ± 0.08), respectively. Based on these results, the cutoff level of the TITRW/FTRW ratio was statistically analyzed according to the receiver operating characteristic curve and it could be set at 1.16 in expiration and at 1.13 in inspiration. We have demonstrated that tracheal ultrasonography is a useful technique for the evaluation of tracheal collapse and it can be a supportive tool together with the radiographic findings for making the correct diagnosis.