Risk factors and outcomes of unrecognised endobronchial intubation in major trauma patients

Heyne, G.; Ewens, Sebastian; Kirsten, Holger; Fakler, Johannes K. M.; Özkurtul, Orkun; Hempel, Gunther; Krämer, Sebastian; Struck, Matthias

doi:10.1136/emermed-2021-211786

Cited by 5 publications

(5 citation statements)

References 25 publications

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“…Mortality rates at 24 h and at 30 days were similar in all groups. This is in line with results from 26 of 616 intubated adult trauma patients of our center [ 11 ]. However, we observed two cases of possibly unnecessary tube thoracostomy due to unrecognized endobronchial intubation [ 12 ].…”

Section: Discussionsupporting

confidence: 92%

“…Tracheal intubation into one mainstem bronchus may cause impairment of gas exchange and lung atelectasis [ 10 ]. Furthermore, unrecognized endobronchial intubation may also lead to avoidable chest tube placement at the unventilated chest side due to absent breath sounds mimicking pneumothorax [ 11 , 12 ]. Although there is previous evidence that children are prone to endobronchial intubation, studies identifying associated factors are scarce [ 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ].…”

Section: Introductionmentioning

confidence: 99%

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Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study

Rost

Donaubauer

Kirsten³

et al. 2022

Children

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Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76–0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04–0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians’ expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study

Rost

Donaubauer

Kirsten³

et al. 2022

Children

Self Cite

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“…Of the 17 patients with no relevant chest injuries and chest tube placement before CT, more than half of them had issues with deep tracheal tube positions, which might have been the reason for chest tube placement. In a previous study, we found unrecognized endobronchial tube malposition detected on CT in 4.2% of the patients [ 25 ]. Seven of them received chest tube placement at the contralateral chest side, four of which were presumably because of the absence of breath sounds.…”

Section: Discussionmentioning

confidence: 99%

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

Struck

Kleber

Ewens

et al. 2022

JCM

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The rate of occult pneumothorax in intubated and mechanically ventilated trauma patients until initial computed tomography (CT) remains undetermined. The primary aims of this study were to analyze initial chest CTs with respect to the thoracic pathology of trauma, the clinical injury severity, and chest tube placement (CTP) before and after CT. In a single-center retrospective analysis of 616 intubated and mechanically ventilated adult patients admitted directly from the scene to the emergency department (ED), 224 underwent CTP (36%). Of these, 142 patients (62%) underwent CTP before CT, of which, 125 (88%) had significant chest injury on CT. Seventeen patients had minor or absent chest injuries, most of which were associated with transient or unrecognized tracheal tube malposition. After CT, CTP was performed in another 82 patients, of which, 56 (68.3%) had relevant pneumothorax and 26 had minor findings on CT. Sixty patients who had already undergone CTP before CT received another CTP after CT, of which, 15 (25%) had relevant pneumothorax and 45 (75%) had functionality issues or malposition requiring replacement. Nine patients showed small pneumothorax on CT, and did not undergo CTP (including four patients with CTP before CT). The physiological variables were unspecific, and the trauma scores were dependent on the CT findings for identifying patients at risk for CTP. In conclusion, the clinical decisions for CTP before CT are associated with relevant false-negative and false-positive cases. Clinical assessment and CT imaging, together, are important indicators for CTP decisions that cannot be achieved by using clinical assessment or CT alone.

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“…Deep placement can impact the carina, leading to hypertension, tachycardia, and bronchospasm ( Varshney et al, 2011 ). Moreover, endobronchial intubation, or unintended placement of the tube in the left or (more commonly) right main bronchi, can result in one-lung ventilation ( De Marchi, 2014 ; Lohser and Slinger, 2015 ; Heyne et al, 2022 ), causing injury to both lungs. The ventilated lung can suffer from tension pneumothorax ( Salem and Baraka, 2013 ) and reduced residual air ( Lohser and Slinger, 2015 ), while the unventilated lung may experience atelectasis, hypoxemia, and hypercapnia ( Lohser and Slinger, 2015 ).…”

Section: Methodsmentioning

confidence: 99%

Playing the pipes: acoustic sensing and machine learning for performance feedback during endotracheal intubation simulation

Steffensen,

Bartnes,

Fuglstad

et al. 2023

Front. Robot. AI

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Objective: In emergency medicine, airway management is a core skill that includes endotracheal intubation (ETI), a common technique that can result in ineffective ventilation and laryngotracheal injury if executed incorrectly. We present a method for automatically generating performance feedback during ETI simulator training, potentially augmenting training outcomes on robotic simulators.Method: Electret microphones recorded ultrasonic echoes pulsed through the complex geometry of a simulated airway during ETI performed on a full-size patient simulator. As the endotracheal tube is inserted deeper and the cuff is inflated, the resulting changes in geometry are reflected in the recorded signal. We trained machine learning models to classify 240 intubations distributed equally between six conditions: three insertion depths and two cuff inflation states. The best performing models were cross validated in a leave-one-subject-out scheme.Results: Best performance was achieved by transfer learning with a convolutional neural network pre-trained for sound classification, reaching global accuracy above 98% on 1-second-long audio test samples. A support vector machine trained on different features achieved a median accuracy of 85% on the full label set and 97% on a reduced label set of tube depth only.Significance: This proof-of-concept study demonstrates a method of measuring qualitative performance criteria during simulated ETI in a relatively simple way that does not damage ecological validity of the simulated anatomy. As traditional sonar is hampered by geometrical complexity compounded by the introduced equipment in ETI, the accuracy of machine learning methods in this confined design space enables application in other invasive procedures. By enabling better interaction between the human user and the robotic simulator, this approach could improve training experiences and outcomes in medical simulation for ETI as well as many other invasive clinical procedures.

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Risk factors and outcomes of unrecognised endobronchial intubation in major trauma patients

Cited by 5 publications

References 25 publications

Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study

Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

Playing the pipes: acoustic sensing and machine learning for performance feedback during endotracheal intubation simulation

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