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

Abstract

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

Real-Time Tracheal Ultrasound vs. Capnography for Intubation Confirmation during CPR Wearing a Powered Air-Purifying Respirator in COVID-19 Era

“…According to one study, it was possible to confirm accurate tube placement with only a brief online tutorial and two practice attempts [17]. In a study on paramedics, tube confirmation could be effectively taught with only a short, simulation-based training session [25]. However, image acquisition is much more difficult during CPR because the patient constantly moves as chest compression progresses.…”

Point-of-Care Ultrasound for the Trauma Anesthesiologist

“…A systematic review of 12 studies with 187 paramedics showed that basic trauma sonography could be taught in 6 to 8 h [ 51 ]. Paramedics can be trained in a short amount of time to use POCUS to identify PTX [ 52 ] and confirmation of endotracheal intubation [ 53 ]. More than half of the trauma patients transported via helicopter experience hypotension, potentially suggesting hypovolemia, and could potentially benefit from an early estimate of hypovolemia/blood loss while still in transport [ 54 ].…”

The Utilization of Handheld Ultrasound Devices in a Prehospital Setting

“…10 The body of current studies regarding portable or handheld ultrasounds is limited in number. Most studies reported include the assessment of EMS personnel to perform ultrasounds, 1,[11][12][13] the feasibility of ultrasounds for triage in the field setting, 14 and the utility of ultrasounds in disaster settings. 15 However, ultrasounds used in prehospital settings in Thailand during the initial phase of diagnosis is limited in the university centers.…”