Protocolized Tracheal and Thoracic Ultrasound for Confirmation of Endotracheal Intubation and Positioning: A Multicenter Observational Study

Abstract

Objectives: To determine the feasibility of a combination of tracheal and thoracic ultrasonography to confirm adequate positioning of endotracheal tube placement in a cohort of critically ill patients. Design: Prospective, multicenter, observational study from January 2019 to May 2020. Setting: Multicenter study conducted in multiple ICUs across four different academic tertiary and community hospitals. Patients: Eligible patients were adults (≥ 18 yr) requiring endotracheal intubation and intensive care. Intervention: Tracheal and thoracic ultrasonography were performed during intubation attempts to rule out esophageal intubations, to detect mainstem intubations, and to confirm and adjust endotracheal tube position. Measurements and Main Results: Among 118 patients, median age was 66 years (interquartile range 56–73 yr), body mass index 28 (interquartile range 25–34), and 63.6 % were males. Using the ultrasound protocol, one esophageal (0.9%) and five main stem intubations (4.2%) were detected. 97.5% of final endotracheal tube positions confirmed by ultrasound were in concordance with the next occurring chest radiograph, with only three (2.5%) requiring minor post-chest radiograph adjustments. Conclusions: A protocolized, systematic approach using tracheal and thoracic ultrasonography can be used to confirm endotracheal intubation, detect main stem intubations, and guide tube positioning in the critically ill. This ultrasonographic approach is easily applicable, safe, and comparable to chest radiography. This approach may serve as a potential alternative or adjunct when chest radiography is not available or ideal. This has the potential to be used for routine intensive care, out-of-hospital or resource-poor settings, or situations which require isolation precautions to mitigate the use of chest radiography.

Point-of-Care Ultrasonography to Confirm Endotracheal Tube Placement

“…Lastly, the authors will review the evaluation of diaphragmatic excursion and the interpretation of sonographic findings while performing these steps. This sequence prioritizes the detection of esophageal intubation, then endobronchial intubation, and enables immediate correction (Mori, Nomura, Hagiwara, Inoue, 2019; Senussi et al, 2020). To perform this assessment, a high-frequency linear probe will be recommended, which will allow for evaluation of the lung and trachea to confirm ETT placement and positioning.…”

Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

“…These include visualizing saline inflated cuff (sensitivity 98.8%, specificity 96.4%) ( 92 ), evaluating pleural sliding on both sides of the chest, ( 90 ) and assessing diaphragmatic movement on both sides simultaneously ( 93 ). Recently, clinical protocols combining these methods have been deployed with promising results in adults but validating studies are lacking in pediatrics ( 94 ). Although direct visualization of the endotracheal tube is feasible in neonates and infants, ( 95 ) this technique is much more challenging and only recommended for providers with experience in bedside ultrasound.…”

Lung ultrasound in blunt chest trauma: A clinical review

“…Absence of lung sliding bilaterally and a ‘double trachea’ sign suggest esophageal intubation, whereas the presence of sliding just in one lung indicates selective intubation. 27…”