Point-of-Care Ultrasound in Airway Evaluation and Management: A Comprehensive Review

Abstract

Airway management is a common and critical procedure in acute settings, such as the Emergency Department (ED) or Intensive Care Unit (ICU) of hospitals. Many of the traditional physical examination methods have limitations in airway assessment. Point-of-care ultrasound (POCUS) has emerged as a promising tool for airway management due to its familiarity, accessibility, safety, and non-invasive nature. It can assist physicians in identifying relevant anatomy of the upper airway with objective measurements of airway parameters, and it can guide airway interventions with dynamic real-time images. To date, ultrasound has been considered highly accurate for assessment of the difficult airway, confirmation of proper endotracheal intubation, prediction of post-extubation laryngeal edema, and preparation for cricothyrotomy by identifying the cricothyroid membrane. This review aims to provide a comprehensive overview of the key evidence on the use of ultrasound in airway management. Databases including PubMed and Embase were systematically searched. A search strategy using a combination of the term “ultrasound” combined with several search terms, i.e., “probe”, “anatomy”, “difficult airway”, “endotracheal intubation”, “laryngeal edema”, and “cricothyrotomy” was performed. In conclusion, POCUS is a valuable tool with multiple applications ranging from pre- and post-intubation management. Clinicians should consider using POCUS in conjunction with traditional exam techniques to manage the airway more efficiently in the acute setting.

Trends in Preoperative Airway Assessment

“…Ultrasound imaging is a noninvasive, simple, and portable tool that may help clinicians with rapid airway assessment and management in operating rooms, emergency departments, and intensive care units [ 41 ]. Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic and therapeutic aid for a wide range of procedures, with many studies highlighting its promising role in airway assessment over the last decade [ 42 , 43 , 44 , 45 ].…”

“…Another clinical application is offering guidance for percutaneous tracheostomy (depth and the presence of any overlying vessels at the proposed insertion site) or identifying the cricothyroid membrane (CTM), preparing attending staff for an emergency cricothyroidotomy in a cannot intubate, cannot ventilate scenario. Also, users may detect subglottic stenosis, predict difficult intubation, detect readiness for extubation (absence of glottic edema), and predict pediatric ETT and double-lumen tube (DLT) size [ 41 , 42 , 43 ].…”

“…Five major ultrasonographic views are used in assessing the upper airway: the suprahyoid, thyrohyoid, thyroid, cricothyroid, and suprasternal views [ 42 ]. Each view assists users in identifying and confirming the prominent landmarks of the upper airway POCUS ( Figure 4 ).…”

“…In the case of a direct laryngoscopy, the hyomental distance ratio can also be used, which is the distance measured with the head in a neutral position and with the cranial extremity in the hyperextension position, measured, of course, by ultrasonography. The most recent data showed that if the hyomental distance is ≤1.09 cm, then intubation will be difficult [ 42 , 49 , 50 ]. Table 5 summarizes the most relevant recent studies regarding ultrasound evaluation of the airway.…”

The 2023 Core Content of advanced emergency medicine ultrasonography

“…Recent cardiac resuscitation guidelines have recognized tracheal ultrasound as an alternative confirmatory test in cardiac arrest patients. The pooled sensitivity and specificity of transtracheal ultrasonography for detecting endotracheal intubation were 98% and 97%, respectively 105–107 . Emerging evidence supports the use of POCUS in detecting conditions such as AV fistula, peripheral vein septic thrombophlebitis, and ocular infections in emergency settings.…”