Diagnostic Accuracy of a 3‐Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department

Abstract

Objectives The aim of this study was to evaluate the diagnostic accuracy of the 3‐point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. Methods This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x‐ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3‐point approach with ultrasonography for detecting inappropriate ETT placement. Results In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8–40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%–100.0%) and 100% (95% CI, 97.9%–100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%–96.0%) and 98.3% (95% CI, 94.8%–99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). Conclusion The 3‐point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.

Lung Ultrasound for Detecting Tracheal and Mainstem Intubation: A Systematic Review and Meta-Analysis

“…Accidental one-lung intubation occurs in about 5% of adult patients in intensive care, 28% of those with cardiac arrest and 10% of those with out-of-hospital endotracheal intubations (Dronen et al 1982;Brunel et al 1989;Timmermann et al 2007). By contrast, pediatric data demonstrate that inadvertent placement of the endotracheal tube into the bronchus during intubation is a fairly common occurrence: up to 18.9% of intubation in pediatric emergency departments and 15.4% of intubations in pediatric intensive care units result in mainstem intubation (Kerrey et al 2009;Nishisaki et al 2013; Alonso Quintela et al 2014;Mori et al 2019;To et al 2021). Our results show that the use of lung ultrasound to detect tracheal and mainstem intubation as an initial strategy in critically ill pediatric patients is associated with high accuracy.…”

“…After careful screening of the titles and abstracts, 76 potentially eligible full-text studies were reviewed in detail. Finally, nine original studies (Kerrey et al 2009 (Kerrey et al 2009;Sim et al 2012;Alonso Quintela et al 2014;Mori et al 2019).…”

“…With regard to the risk of participant selection bias, eight studies (88.8%) did not report whether participants were consecutively enrolled and thus were labeled as having unclear risk (Kerrey et al 2009;Susti c et al 2010;Sim et al 2012;Alonso Quintela et al 2014;Ramsingh et al 2016;Mori et al 2019;Parab et al 2019;Men and Yan 2020). In the assessment of reference standard, three studies (33.3%) did not describe whether the performers of fiber-optic bronchoscopy or chest X-ray were unaware of the lung-ultrasound results and thus were rated as having unclear risk Lung ultrasound for tracheal intubation position F. M. YANG et al (Sim et al 2012;Alonso Quintela et al 2014;Mori et al 2019). Overall, the quality of the included studies was high (Fig.…”

“…The direct method of tracheal ultrasound or the indirect method of looking for pleural sliding and motion of the diaphragm have been used to confirm correct tracheal tube placement. However, the accuracy of lung ultrasound in detecting endotracheal versus mainstem intubation is inconsistent in different studies (Kerrey et al 2009;Susti c et al 2010;Sim et al 2012;Alonso Quintela et al 2014;Alvarez-D ıaz et al 2015;Ramsingh et al 2016;Mori et al 2019;Parab et al 2019;Men and Yan 2020). The primary aim of this systematic review and meta-analysis was to compile all available data from published studies on the ability of lung ultrasound to detect tracheal and mainstem intubation.…”

Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS)

“…POCUS ist genauer bei Pleuraergüssen oder Pneumothorax und hilft beim Durchführen der Nadeldekompression und Thorakostomie. Es wurde auch als Hilfsmittel zur Bestätigung der korrekten Platzierung des Trachealtubus beschrieben, allerdings ist die Evidenz bei Kindern begrenzt [ 119 , 120 ].…”