Defining the learning curve of point-of-care ultrasound for confirming endotracheal tube placement by emergency physicians

Abstract

BackgroundUnrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in the emergency department. Recent studies have demonstrated that point-of-care ultrasound (POCUS) may be a useful adjunct for confirming endotracheal tube placement; however, the amount of practice required to become proficient at this technique is unclear. The purpose of this study is to determine the amount of practice required by emergency physicians to become proficient at interpreting ultrasound video clips of esophageal and endotracheal intubations.MethodsEmergency physicians and emergency medicine residents completed a baseline interpretation test followed by a 10 min online tutorial. They then interpreted POCUS clips of esophageal and endotracheal intubations in a randomly selected order. If an incorrect response was provided, the participant completed another practice session with feedback. This process continued until they correctly interpreted ten consecutive ultrasound clips. Descriptive statistics were used to summarize the data.ResultsOf the 87 eligible physicians, 66 (75.9 %) completed the study. The mean score on the baseline test was 42.9 % (SD 32.7 %). After the tutorial, 90.9 % (60/66) of the participants achieved proficiency after one practice attempt and 100 % achieved proficiency after two practice attempts. Six intubation ultrasound clips were misinterpreted, for a total error rate of 0.9 % (6/684). Overall, the participants had a sensitivity of 98.3 % (95 % CI 96.3–99.4 %) and specificity of 100 % (95 % CI 98.9–100 %) for detecting correct tube location. Scans were interpreted within an average of 4 s (SD 2.9 s) of the intubation.ConclusionsAfter a brief online tutorial and only two practice attempts, emergency physicians were able to quickly and accurately interpret ultrasound intubation clips of esophageal and endotracheal intubations.Electronic supplementary materialThe online version of this article (doi:10.1186/s13089-015-0031-7) contains supplementary material, which is available to authorized users.

Diagnostic Accuracy of Ultrasound for Confirmation of Endotracheal Tube Placement

“…However, there was no significant difference in accuracy with respect to the training protocol. Of note, a prior study has demonstrated that the learning curve for transtracheal POCUS is relatively rapid . POCUS operator experience, specialty, and level of training varied in the included trials, but again, no significant difference was identified on subgroup analysis.…”

Comparison of Static versus Dynamic Ultrasound for the Detection of Endotracheal Intubation

“…However, the use of ultrasound for ETT confirmation has been suggested to have a rapid learning curve. 15 Nonetheless, further studies are advised to determine whether the accuracy of static vs. dynamic techniques differs in less experienced providers.…”

Lung Ultrasound: The Emerging Role of Respiratory Therapists

“…12). 83 Positioning the linear probe transversely over the cricothyroid membrane during the intubation process results in confirmatory reverberation artifacts, known as the bullet sign. 84 Similarly, esophageal intubation is detected by a double tract sign (Fig.…”

“…Both the tracheal and the esophageal tracts are seen in Figure 13, indicating esophageal intubation. 83 A systematic review and meta-analysis concluded that trans-tracheal ultrasound confirms endotracheal intubation with superior sensitivity and specificity. The review also confirmed this technique's utility in emergency intubations as an initial assessment before the final confirmation with capnography.…”