Sonographic Evaluation of the Endotracheal Tube Position in the Neonatal Population: A Comprehensive Review and Meta-Analysis

Abstract

BackgroundEndotracheal intubation in neonates is challenging and requires a high level of precision, due to narrow and short airways, especially in preterm newborns. The current gold standard for endotracheal tube (ETT) verification is chest X-ray (CXR); however, this method presents some limitations, such as ionizing radiation exposure and delayed in obtaining the radiographic images, that point of care ultrasound (POCUS) could overcome.Primary ObjectiveTo evaluate ultrasound efficacy in determining ETT placement adequacy in preterm and term newborns.Secondary ObjectiveTo compare the time required for ultrasound confirmation vs. time needed for other standard of care methods.Search MethodsA search in Medline, PubMed, Google Scholar and in the Cochrane Central Register of Controlled Trials (CENTRAL) was performed. Our most recent search was conducted in September 2021 including the following keywords: “newborn”, “infant”, “neonate”, “endotracheal intubation”, “endotracheal tube”, “ultrasonography”, “ultrasound”.Selection CriteriaWe considered randomized and non-randomized controlled trials, prospective, retrospective and cross-sectional studies published after 2012, involving neonatal intensive care unit (NICU) patients needing intubation/intubated infants and evaluating POCUS efficacy and/or accuracy in detecting ETT position vs. a defined gold-standard method. Three review authors independently assessed the studies' quality and extracted data.Main ResultsWe identified 14 eligible studies including a total of 602 ETT evaluations in NICU or in the delivery room. In about 80% of cases the gold standard for ETT position verification was CXR. Ultrasound was able to identify the presence of ETT in 96.8% of the evaluations, with a pooled POCUS sensitivity of 93.44% (95% CI: 90.4–95.75%) in detecting an appropriately positioned ETT as assessed by CXR. Bedside ultrasound confirmation was also found to be significantly faster compared to obtaining a CXR.ConclusionPOCUS appears to be a fast and effective technique to identify correct endotracheal intubation in newborns. This review could add value and importance to the use of this promising technique.

A Scoping Review of Ultrasonographic Techniques in the Evaluation of the Pediatric Airway

“…In a recent large meta‐analysis including 14 studies and 602 newborn patients, ultrasound identified the presence of ETT in 96.8% of the evaluations. The mean time to confirmation of ETT was also substantially lower with ultrasound 23 …”

“…It has been studied in neonates and children in neonatal intensive care units, pediatric intensive care units, emergency departments, and by a transport team. It compares favorably with chest x‐ray and capnography in its ability to locate the tube endotracheally and to ensure that it is not in a mainstem bronchus, and may augment other ETT verification methods 21–25 …”

“…Endotracheal location of the ETT using ultrasound has been performed and validated across multiple studies as a fast and accurate method in pediatric and neonatal patients 21–25 . The skill also appears quickly acquired.…”

Point-of-Care Ultrasound for the Tip of the Endotracheal Tube: A Neonatologist Perspective

“…between esophageal and tracheal intubation 1,2 . The need to position an unstable newborn during X-ray imaging may also result in tube dislodgement and even extubation.…”

FOCUS more on POCUS

“…The total time taken by ultrasound to confirm ETT tip location and assessing the distance between the tip and arch of the aorta could have given additional information regarding how faster the procedure can be done in emergency or intensive care setting since the time taken by the procedure might vary from seconds to minutes which is much quicker than chest X-ray. 3 …”