Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting

Abstract

BACKGROUND: Patients intubated in the prehospital setting require quick and definitive confi rmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no defi nitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confi rmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confi rmed with disposable fi beroptic bronchoscopy. METHODS: Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, fl exible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identifi ed ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of diffi culty were measured. RESULTS: Residents accurately identifi ed the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very diffi cult). No tubes were damaged or dislodged. CONCLUSION: While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confi rmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.

Using a Disposable Flexible Fiberoptic Scope as a Bougie for Difficult Intubation

“…Disposable fiberoptic bronchoscopes have been previously described to be used in emergent settings to confirm the position of endotracheal tubes. [ 8 ] Bronchoscopes can be threaded through previously placed endotracheal tubes and have been proven to be accurate, quick, and relatively easy to do. Inspired by use of bronchoscopes, the senior anesthetist who performed the intubation mentioned in the cases described, chose to disassemble the digital head to thread the endotracheal tube after confirming the placement of the bronchoscope tip between the vocal cords.…”

Continuous monitoring of endotracheal tube position with near infrared light

“…The use of ultrasound imaging for ETT placement confirmation or endoscopy has been reported; however, their limited availability, requirement for user experience, labor intensiveness, and cost hinder their use in clinical settings. Like CXR, these monitoring methods may only provide a single moment-in-time assessment of placement rather than a continuous assessment of tube position 4 , 19 , 21 , 22 . Currently, SonarMed (formally named AirWave) is an FDA-approved device for real-time ETT airway monitoring for neonates.…”

“…Like CXR, these monitoring methods may only provide a single moment-in-time assessment of placement rather than a continuous assessment of tube position. 4 , 19 , 21 , 22 Currently, SonarMed (formally named AirWave) is an FDA-approved device for real-time ETT airway monitoring for neonates. However, an earlier pilot study showed notable discrepancies in the results compared to those obtained with CXR.…”

Tele-Simulated Instruction and Learner Perceptions of Fiberoptic Intubation and Nasopharyngoscopy: A Pilot Study

“…Fiberoptic nasopharyngoscopy can serve as a lifesaving airway skill. [10][11][12][13][14][15][16] Allowing visualization of laryngeal anatomy provides valuable diagnostic information in angioedema, airway obstruction, and many other head and neck airway emergencies. While intubations are frequently encountered in practice, fiberoptic nasopharyngoscopy is far less often used but extremely useful, making it ideal for simulation-based training.…”