The feasibility of determining the position of an endotracheal tube in neonates by using bedside ultrasonography compared with chest radiographs

Abstract

Background. Neonates in our neonatal intensive care unit (NICU) receive a large amount of radiation with X-rays (XRs) being done daily, even more often with reintubation, repositioning of endotracheal tubes (ETTs) and confirmation thereof, which has been our NICU policy for many years. Objective. To investigate the feasibility of determining the position of ETTs in neonates by using bedside ultrasonography (BUS), and to compare the results with those obtained from chest XR (CXR) findings. Methods. A prospective, cross-sectional study was done on intubated neonates in the NICU at Universitas Academic Hospital, Bloemfontein, to determine the position of ETTs by using BUS. Results. Thirty intubated patients included in this study had a median age of 13.5 days and a median weight of 1.6 kg. Ninety-three per cent of ETT placements were considered optimal when visualised by BUS, while 73.3% were considered to be placed optimally when CXR was viewed. When CXR and BUS findings were compared regarding optimal placing, the agreement was poor (κ=0.10; 95% confidence interval -0.2 -0.4). In four patients, the distance from the aortic arch to the tip of the ETT was outside the expected range of 1.5 -2.2 cm: in two patients it was <1.5 cm (6.7%) and in the other two >2.25 cm (6.7%). BUS measurements were done mainly in extended head (53.3%) or neutral (36.7%) position. Conclusion.Although poor agreement between CXR and BUS findings was obtained, possibly because of handling of patients with secondary shifting of ETTs, BUS was found not to be comparable with CXR, but an alternative feasible method to determine the optimal position of ETTs in the trachea in neonates when using other reference points, with the added advantage of no radiation exposure.

Ultrasonography for Verification of Endotracheal Tube Position in Neonates and Infants

“…10 Most subsequent studies reported manipulating the head and neck slightly for better US image acquisition. [11][12][13][14] Sethi et al and Dennington et al also oscillated the ETT to aid visualization and did not report adverse events. 11,12 Concerned about the potential risks of oscillating the ETT, Lingle tried using an US "standoff pad" over the infant's chest and neck instead and reported that it facilitated visualization and minimized handling 15 ; however, further studies have not evaluated this technique.…”

“…Slovis and Poland established the close correlation between the aortic arch on US and the carina on XR that has been used and verified in most of the subsequent studies. 10,12,16 The majority of authors concurred that optimal ETT placement as seen on US is between 1 and 1.5 cm above the aortic arch, 10,11,14,17 though one study concluded optimal ETT tip-to-aorta distance to be < 1 cm. 16 Dennington et al chose the superior portion of the right pulmonary artery as the US anatomic equivalent of the carina and their landmark for measuring ETT depth; the group reported 100% US-XR concordance.…”

“…12 Both the thyroid and the sternum have been proposed as potential cephalic US landmarks in small case series. 14,15 In contrast to the other studies that primarily utilized the midsagittal suprasternal view, Alonso Quintela et al determined ETT position using the sliding lung sign of visceralparietal pleural movement with the US transducer placed along the mid-axillary line of the hemithorax bilaterally. 13 Their study included older children with whom the midsagittal sternal view is lost.…”

Ultrasound for Endotracheal Tube Tip Position in Term and Preterm Infants

“…Ideally, ETT placement should be checked at the bedside using a method that is fast, noninvasive, reliable, tolerable, easy to learn and use, and without any need for radiation. Different methods are currently employed for this purpose, including the following: • clinical tests: thoracic auscultation and assessment of thoracic excursion, clinical signs (heart rate and oxygen saturation), presence of condensation in the tube, absence of stomach distension, and palpation of the ETT at the suprasternal notch; • direct laryngoscopy, which requires an expert operator and involves a temporary interruption of resuscitation maneuvers; • measuring end-tidal CO 2 (etCO 2 ) using a colorimetric method (recommended by the 2020 neonatal resuscitation guidelines [3]); this method can confirm whether the ETT is in the airways but cannot rule out a bronchial intubation or confirm the correct distance from the carina and glottis; • chest X-ray (CXR), which is currently the most often used method, but it is time-consuming, involves exposure to radiation, and is not always readily available in an emergency setting, and esophageal intubations may also occasionally be misinterpreted on a single anteroposterior scan; • ultrasound (US), a method still little investigated in clinical practice, but with promising results; it can be done using different acoustic windows (pulmonary US, diaphragmatic US, tracheal US, and suprasternal US in the sagittal position) [1,4] and different markers (aortic arch [5,6], aortic arch combined with thyroid [7], and right pulmonary artery (RPA) [8,9]. US is increasingly used every day in neonatology.…”

The feasibility of bedside ultrasound in confirmation of Endotracheal tube position in neonates compared with CXR&nbsp;

“…Most of them demonstrated no statistically signi cant differences between the US and CXR in identifying the correct ETT position (2, 9, 10, and 11) nevertheless de Kock et al showed there was poor agreement between ndings of CXR and US (12) Our study results showed that bedside ultrasound had acceptable accuracy comparison to CXR for detecting the correct position of ETT in the neonate and also, was the faster and safer method than CXR with no complication during performance.…”