Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement

Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation

OBJECTIVE

Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases.

METHODS

We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed.

RESULTS

Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction.

CONCLUSIONS

Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.

Current Role of Emergency US in Patients with Major Trauma

In patients with major trauma, focused abdominal ultrasonography (US) often is the initial imaging examination. US is readily available, requires minimal preparation time, and may be performed with mobile equipment that allows greater flexibility in patient positioning than is possible with other modalities. It also is effective in depicting abnormally large intraperitoneal collections of free fluid, which are indirect evidence of a solid organ injury that requires immediate surgery. However, because US has poor sensitivity for the detection of most solid organ injuries, an initial survey with US often is followed by a more thorough examination with multidetector computed tomography (CT). The initial US examination is generally performed with a FAST (focused assessment with sonography in trauma) protocol. Speed is important because if intraabdominal bleeding is present, the probability of death increases by about 1% for every 3 minutes that elapses before intervention. Typical sites of fluid accumulation in the presence of a solid organ injury are the Morison pouch (liver laceration), the pouch of Douglas (intraperitoneal rupture of the urinary bladder), and the splenorenal fossa (splenic and renal injuries). FAST may be used also to exclude injuries to the heart and pericardium but not those to the bowel, mesentery, and urinary bladder, a purpose for which multidetector CT is better suited. If there is time after the initial FAST survey, the US examination may be extended to extra-abdominal regions to rule out pneumothorax or to guide endotracheal intubation, vascular puncture, or other interventional procedures.

Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: a feasibility study

OBJECTIVE

The purpose of our study was to evaluate the usefulness of bedside ultrasonography in verifying endotracheal tube placement in the pediatric population.

METHODS

This study consisted of 2 phases. In phase I, subjects were examined while intubated and after extubation to determine the presence of the endotracheal tube by applying each of 2 ultrasound transducers to the cricothyroid membrane. In phase II, pediatric patients were examined in the emergency department during intubation or immediately after intubation to ascertain proper endotracheal tube placement by using bedside ultrasonography. These results were compared with the results obtained with a colorimetric end-tidal carbon dioxide detector and chest radiographs.

RESULTS

Forty-nine and 50 patients (age: 1 day to 17 years) were recruited in the first and second phases of the study, respectively. The endotracheal tube was detected in all 99 patients by using bedside ultrasonography. Two views were required to show accurately the presence of the endotracheal tube in the trachea. Visualization was obtained in all cases, although short necks and cervical collars made the procedure more challenging. The sniffing position allowed for the best acquisition of high-quality images. Our linear transducer provided the best images but, because of its size, it was not ideal when space was limited. Therefore, the curvilinear transducer was used exclusively for phase II. During phase II, the mean times to acquire bedside ultrasonographic images of the endotracheal tube through the cricothyroid membrane and to obtain a chest radiograph were 17.1 seconds and 14.0 minutes, respectively. In 3 cases, bedside ultrasonographic images proved to be invaluable when the colorimetric end-tidal carbon dioxide detector yielded false-negative or equivocal readings.

CONCLUSIONS

Bedside ultrasonography can be used to accurately and rapidly determine the presence of the endotracheal tube within the trachea in pediatric patients.

Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis

Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.