Where's the Tube? Evaluation of Hand-held Ultrasound in Confirming Endotracheal Tube Placement

Abstract

Introduction:The diagnosis of endotracheal tube (ETT) mal-position may be delayed in extreme environments. Several methods are utilized to confirm proper ETT placement, but these methods can be unreliable or unavailable in certain settings. Thoracic sonography, previously utilized to detect pneumothoraces, has not been tested to assess ETT placement.Hypothesis:Thoracic sonography could correlate with pulmonary ventilation, and thereby, help to confirm proper ETT placement.Methods:Thirteen patients requiring elective intubation under general anesthesia, and data from two trauma patients were evaluated. Using a portable, hand-held, ultrasound (PHHU) machine, sonographic recordings of the chest wall visceral-parietal pleural interface (VPPI) were recorded bilaterally in each patient during all phases of airway management: (1) preoxygenation; (2) induction; (3) paralysis; (4) intubation; and (5) ventilation. Results: The VPPI could be well-imaged for all of the patients. In the two trauma patients, right mainstem intubations were noted in which specific pleural signals were not seen in the left chest wall VPPI after tube placement. These signs returned after correct repositioning of the ETT tube. In all of the elective surgery patients, signs correlating with bilateral ventilation in each patient were imaged and correlated with confirmation of ETT placement by anesthesiology.Conclusions:This report raises the possibility that thoracic sonography may be another tool that could be used to confirm proper ETT placement. This technique may have merit in extreme environments, such as in remote, prehospital settings or during aerospace medical transports, in which auscultation is impossible due to noise, or capnography is not available, and thus, requires further scientific evaluation.

Sonographic diagnosis of pneumothorax

“…Occasionally, in the absence of lung sliding, a vertical movement of the pleural line synchronous to the cardiac rhythm can be detected. It is called the ''lung pulse'', and can be caused by the transmission of the heart beats through a consolidated motionless lung, as well as by apnea subsequent to pharmacological paralysis or simply by breath holding in the absence of disease [15,27]. This sign is very useful to differentiate PNX from other conditions characterized by the absence of horizontal pleural motion.…”

Postępowanie w niespodziewanych trudnych drogach oddechowych u dzieci — stanowisko Sekcji Anestezjologii i Intensywnej Terapii Dziecięcej, Sekcji Przyrządowego Udrażniania Dróg Oddechowych Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii oraz Po

“…In the operating theatre, E T CO 2 (capnography) is used while a CO 2 detector device may be used as an alternative in out-of-theatre settings [50][51][52]. The correct placement of the TT may be confirmed with ultrasound and a fibre-optic scope [53][54][55][56]. Re: (b).…”

“…The correct depth of TT insertion may sometimes require radiological confirmation (CXR) [31]. The tracheal tube placement can also be confirmed with an ultrasound [53][54][55][56]59]. A fibre--optic scope may be used for TT placement confirmation in some clinical situations.…”

A novel method to position an endotracheal tube at the correct depth using an infrared sensor stylet

“…[7][8][9][10][11][12][13][14] Recently, ultrasound, video sensor, and radio-frequency identification (RFID) have been introduced as alternative methods. [15][16][17][18] Chest radiography is considered the gold standard for confirming the correct depth of ETT placement; however, it is not possible to use chest radiography in a situation outside the hospital, and it is difficult to use it frequently in the intensive care unit because of the inherent radiation exposure. 7,18 Capnography, which estimates end-tidal carbon dioxide (CO 2 ) by using infrared rays, is one of the best methods to confirm ETT placement; however, it cannot calculate the distance from the tip of the ETT to the carina.…”