Auscultation versus Point-of-care Ultrasound to Determine Endotracheal versus Bronchial Intubation

Point-of-Care Ultrasonography to Confirm Endotracheal Tube Placement: A Review for the Emergency Nurse Practitioner

Ensuring correct placement of the endotracheal tube (ETT) during intubation is an important step to avoid complications. Appropriate placement of the ETT can be challenging and, if done incorrectly, can lead to complications such as hypoxemia, atelectasis, hyperinflation, barotrauma, cardiovascular instability, end organ damage, and even death. Although several procedures exist to help assess ETT confirmation, all have limitations, are not always reliable, and vary in their degree of accuracy. Point-of-care ultrasound (POCUS) has emerged as a useful tool in the emergency department for quick diagnosis and treatment of many emergency conditions (Gonzalez et al., 2020). The purpose of this paper is to describe a systematic approach for the emergency nurse practitioner to use POCUS to assess proper endotracheal placement and the positioning within the trachea based on prior studies that compare this modality to traditional ones.

Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management

Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.

Real-Time Tracheal Ultrasound vs. Capnography for Intubation Confirmation during CPR Wearing a Powered Air-Purifying Respirator in COVID-19 Era

This study aimed to compare the accuracy of real-time trans-tracheal ultrasound (TTUS) with capnography to confirm intubation in cardiopulmonary resuscitation (CPR) while wearing a powered air-purifying respirator (PAPR). This setting reflects increased caution due to contagious diseases. This single-center, prospective, comparative study enrolled patients requiring CPR while wearing a PAPR who visited the emergency department of a tertiary medical center from December 2020 to August 2022. A physician performed the TTUS in real time and recorded the tube placement assessment. Another healthcare provider attached waveform capnography to the tube and recorded end-tidal carbon dioxide (EtCO2) after five ventilations. The accuracy and agreement of both methods compared with direct laryngoscopic visualization of tube placement, and the time taken by both methods was evaluated. Thirty-three patients with cardiac arrest were analyzed. TTUS confirmed tube placement with 100% accuracy, sensitivity, and specificity, whereas capnography demonstrated 97% accuracy, 96.8% sensitivity, and 100% specificity. The Kappa values for TTUS and capnography compared to direct visualization were 1.0 and 0.7843, respectively. EtCO2 was measured in 45 (37-59) seconds (median (interquartile range)), whereas TTUS required only 12 (8-23) seconds, indicating that TTUS was significantly faster (p < 0.001). No significant correlation was found between the physician's TTUS proficiency and image acquisition time. This study demonstrated that TTUS is more accurate and faster than EtCO2 measurement for confirming endotracheal tube placement during CPR, particularly in the context of PAPR usage in pandemic conditions.

Regional anesthesia and POCUS in the intensive care unit

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Comparison of lung ultrasound technique <em>versus</em> clinical method to evaluate the accuracy of size and placement of left endobronchial double lumen tube in patients undergoing elective thoracic surgery: a prospective observational study

Anthropometric measurements like height and gender have been frequently found to be inaccurate in prediction of size of double lumen tube (DLT). A tracheal ultrasonography (TUS) is a technique that can be used to predict the size of DLT and its correct placement for lung isolation. We aim to check the accuracy of ultrasound over clinical methods. This prospective study included 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) with DLT. The groups were assessed for the size of DLT by either anthropometric measurement using height and gender (Group C) or ultrasound method (Group U). Further, the accuracy of placement of DLT was assessed through, either lung auscultation in group C or various ultrasonographic and ventilatory parameters such as lung isolation in the first attempt (lung sliding and lung pulse sign), oxygenation status and peak airway pressure, in group U. Surgeon satisfaction score was also compared in both the groups. The accuracy of predicted DLT size between Group C and Group U was statistically significant (p=0.044). In Group C, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group U, the mismatch was only 32.4%. The accuracy of DLT placement through group C was 41% as compared to 79% in Group U. Surgeon satisfaction score was also significantly higher in Group U as compared to Group C (p=0.0028). Thus, our study suggests that tracheal and chest ultrasonography for DLT size selection and placement for lung isolation is superior to clinical methods.

Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room

Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.

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

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.

Point-of-Care Ultrasound: A Moving Picture Is Worth a Thousand Tests

The effective utilization of point-of-care ultrasound may decrease the utilization of conventional diagnostic modalities. This review describes the various pathologies that can be effectively and rapidly identified with point-of-care cardiac, lung, abdominal, vascular airway, and ocular ultrasonography.

Point-of-care ultrasound to confirm the position of bronchial blockers in children

PURPOSE

We described the accuracy of ultrasound in determining the position of bronchial blockers (BBs) in children underwent thoracoscopic surgery.

METHODS

We enrolled 52 children with ASA grade I-III who received thoracoscopic surgery with placement of BBs. Point-of-care ultrasound was performed according to the BLUE protocol. The ultrasound-guided lung sliding sign and curtain sign were used to assess the position of BBs. The accuracy of ultrasound in evaluating the position of BBs, as well as the accuracy and operating time of sliding sign and curtain sign at each examination point were recorded and compared.

RESULTS

The accuracy of ultrasound in evaluating the position of BBs was 88% (46/52, 95% CI 0.69-0.97). When using the curtain sign to assess the position of BBs, the accuracy was 90% (94/104, 95% CI 0.78-0.96), which was significantly higher than when using the sliding sign (65% (136/208), 95% CI 0.55-0.74) (p = 0.002). The accuracy of curtain sign at the left mid-axillary line-diaphragm and the right mid-axillary line-diaphragm was respectively 96% (50/52, 95% CI 0.80-0.99) and 84% (44/52, 95% CI 0.65-0.95), which were higher than that of sliding sign at upper blue points and lower blue points. There was no significant difference in the operating time between two ultrasound signs (the curtain sign, 13.4 ± 8.2 s vs. the lung sliding sign, 16.2 ± 10.0 s, p = 0.065).

CONCLUSION

Point-of-care ultrasound can effectively assess the position of BBs. The accuracy of using the curtain sign at the mid-axillary line-diaphragm is higher than that of using the lung sliding sign at the anterior chest wall.

Airway Ultrasound for Anesthesia and in Intensive Care Patients-A Narrative Review of the Literature

Ultrasound is an everyday diagnostic tool. In anesthesia and intensive care, it has a role as an adjuvant for many procedures, including the evaluation of the airway. Ultrasound airway evaluation can help predict a difficult airway, visualize the proper positioning of an intubation cannula, or evaluate the airway post-intubation. Protocols need to be established for the better integration of ultrasound in the airway evaluation, however until a consensus is reached in this respect, the ultrasound is a reliable aid in anesthesia and intensive care.

Improvement in Validity and Reliability of Airway Assessment Using Ultrasonography by Novice Personnel: A Learning Cohort Study

PURPOSE

To assess improvements in the validity and reliability of novices' skills in performing ultrasonography for airway assessment.

PATIENTS AND METHODS

A learning cohort study was conducted with 20 anesthesiology residents and 10 volunteers in the Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University. The four parameters of airway assessment were soft tissue thickness at the level of 1) hyoid bone (STT-HY), 2) true vocal cords (STT-VC), 3) thyroid isthmus (STT-TI), and 4) suprasternal notch (STT-SN). The magnitude of discrepancies between the residents' and experienced anesthesiologists' measurements was evaluated over the sequence of measurements in the 10 volunteers.

RESULTS

The mean ultrasonic measurements of STT-HY by the experienced anesthesiologists and residents were significantly different (11.09 ± 3.14 mm vs 8.53 ± 3.02 mm, respectively; P = 0.008), whereas measurements of STT-VC, STT-TI, and STT-SN were not (7.18 ± 1.70 vs 7.14 ± 1.93, P = 0.32; 7.81 ± 2.14 vs 7.73 ± 2.19, P = 0.62; and 11.32 ± 3.33 vs 10.30 ± 3.02, P = 0.35, respectively). The mean discrepancy between the residents' and experienced anesthesiologists' measurements was close to zero throughout the sequence of measurements of STT-TI and STT-VC. However, the residents' measurements of STT-HY and STT-SN were considerably lower than those of anesthesiologists. The range of discrepancies between residents and experienced anesthesiologists in each sequential measurement was wide for all measurements, particularly for the measurement values of STT-HY, and the standard deviation of the discrepancies did not decrease over the sequence of measurements.

CONCLUSION

Over the sequence of measurements for airway assessment in 10 volunteers by 20 residents in this learning trial, we found no evidence of improvement in measurement accuracy. Discrepancies between the residents' and anesthesiologists' measurements and the variability in discrepancy across residents were greatest in the measurement of STT-HY.

Lung Ultrasound to Assess One Lung Ventilation: A Pediatric Case Series

Objectives: One lung ventilation (OLV) is the preferred ventilation technique for thoracoscopy as it provides a better exposure of the operative field and grants the protection of the healthy lung. Preoperative evaluation of lung exclusion is necessary and different methods are available. In recent years lung ultrasound (US) gained popularity and its use for monitoring the endotracheal tube position is widely reported. The existing evidence on adults addresses lung US as effective, yet only few data are available in children. Therefore, we present our experience with lung US as verification method for pediatric OLV. Methods: All patients undergoing OLV for video-assisted thoracoscopic surgery from January 2019 to May 2021 and for whom lung exclusion was confirmed through lung US were involved. Lung exclusion was considered effective when absence of lung motion and presence of lung pulse were encountered. When lung US did not match these criteria, repositioning of the endobronchial device followed by US verification was performed. When lung US met the exclusion criteria surgery was started and direct thoracoscopic observation was used to verify lung exclusion. Results: A total of 20 patients, accounting for 22 procedures, were involved. Absence of lung motion and presence of lung pulse were assessed in the operative-side lung for all patients. Lung exclusion was confirmed through thoracoscopy. Postoperative lung US proved the reappearance of lung motion in the previously excluded lung. Conclusions: In our center experience lung US resulted to be a safe, effective, and time-saving verification method for OLV. Further studies are needed to define its sensitivity and specificity.

Safe ultrasound-guided percutaneous tracheostomy in eight steps and necessary precautions in COVID-19 patients

Percutaneous tracheostomy has been considered the standard method today, the bronchoscopy-guided technique being the most frequently performed. A safe alternative is ultrasound-guided percutaneous tracheostomy, which can be carried out by the surgeon, avoiding the logistical difficulties of having a specialist in bronchoscopy. Studies prove that the efficacy and safety of the ultrasound-guided technique are similar when compared to the bronchoscopy-guided one. Thus, it is of paramount importance that surgeons have ultrasound-guided percutaneous tracheostomy as a viable and beneficial alternative to the open procedure. In this article, we describe eight main steps in performing ultrasound-guided percutaneous tracheostomy, highlighting essential technical points that can reduce the risk of complications from the procedure. Furthermore, we detail some precautions that one must observe to reduce the risk of aerosolization and contamination of the team when percutaneous tracheostomy is indicated in patients with COVID-19.

Use of Electronic Auscultation in Full Personal Protective Equipment to Detect Ventilation Status in Selective Lung Ventilation: A Randomized Controlled Trial

Chest auscultation is the first procedure performed to detect endotracheal tube malpositioning but conventional stethoscopes do not conform to the personal protective equipment (PPE) protocol during the COVID-19 pandemic. This double-blinded randomized controlled trial evaluated the feasibility of using ear-contactless electronic stethoscope to identify endobronchial blocker established selective lung ventilation, simulating endobronchial intubation during thoracic surgery with full PPE. Conventional and electronic auscultation was performed without and with full PPE, respectively, of 50 patients with selective lung ventilation. The rates of correct ventilation status detection were 86 and 88% in the conventional and electronic auscultation groups (p = 1.00). Electronic auscultation revealed a positive predictive value of 87% (95% CI 77 to 93%), and a negative predictive value of 91% (95% CI 58 to 99%), comparable to the results for conventional auscultation. For detection of the true unilateral lung ventilation, the F1 score and the phi were 0.904 and 0.654, respectively for conventional auscultation; were 0.919 and 0.706, respectively for electronic auscultation. Furthermore, the user experience questionnaire revealed that the majority of participant anesthesiologists (90.5%) rated the audio quality of electronic lung sounds as comparable or superior to that of conventional acoustic lung sounds. In conclusion, electronic auscultation assessments of ventilation status as examined during thoracic surgery in full PPE were comparable in accuracy to corresponding conventional auscultation assessments made without PPE. Users reported satisfactory experience with the electronic stethoscope.

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

Precise positioning of the left or right main bronchus is a prerequisite for effective lung isolation in thoracic surgeries. This study aimed to clarify the ability of lung ultrasound to detect tracheal and mainstem intubation. Studies that investigated the ability of lung ultrasound to detect tracheal and mainstem intubation were searched from PubMed and ScienceDirect databases from their inception to March 2021. The pooled accuracy of this method and its sensitivity and specificity were computed with a fixed-effects model using Stata 14.0. Nine eligible articles that involved a total of 617 participants were included in this systematic review and meta-analysis. Overall, the accuracy of lung ultrasound in detecting tracheal and mainstem intubation was 86.7%, with a sensitivity of 93.0% and a specificity of 75.0%. Subgroup analysis revealed that the accuracy remained high regardless of patient age, ultrasonic method, sample size, study design or ultrasonic skills training. Sensitivity analysis indicated that the results were stable. Deeks' test showed no publication bias. These findings imply that lung ultrasound is an effective method for detecting tracheal and mainstem intubation.

Age-Related Changes in Upper Airway Anatomy Via Ultrasonography in Pediatric Patients

PURPOSE

Ultrasonography is a portable, noninvasive tool that may be used to evaluate the upper airway. The purpose of our study was to present a systematic approach to identify salient features of the pediatric airway and determine whether ultrasonography can identify anatomical changes that occur with growth and development.

METHODS

We present a prospective, observational trial where patients included were between 1 day and 10 years of age presenting for elective surgery who had no known history of unfavorable airway pathology. We sequentially obtained 5 ultrasound views under anesthesia: (1) sagittal sternal notch view of the trachea, (2) sagittal longitudinal view of trachea (LT), (3) axial view at the level of the vocal cords (AVC), (4) axial view at the level of the cricoid membrane (AC), and (5) sagittal longitudinal submental space view (SM). A broadband linear array transducer was used to identify airway structures and perform measurements.

RESULTS

Eighty-four percent of enrolled patients underwent airway imaging and were analyzed using multiple regression and Spearman correlation (ρ). In view 1, tracheal diameter via sagittal sternal notch view was immeasurable because of air disturbance. In the LT view, the distance from the skin to the cricothyroid membrane (LT1) did not statistically increase with age in days (P = 0.06); however, the distance from the cricoid to thyroid cartilage (LT2) did correlate to age (P < 0.001; 99% confidence interval [CI], 1.8 × 10-5, 7.7 × 10-5; ρ = 0.77, P = 0.001). We found a statistically significant relationship between age and the distance between the anterior and posterior commissures (AVC2; P < 0.001; 99% CI, 1.0 × 10-4, 1.7 × 10-4; ρ = 0.80, P < 0.001), the distance from the skin to the posterior commissure (AVC3; P < 0.001; 99% CI, 9.6 × 10-5, 2.0 × 10-4; ρ = 0.73, P < 0.001), the distance to the cricoid cartilage (AC; P < 0.001; 99% CI, 2.0 × 10-5, 7.7 × 10-5; ρ = 0.66, P < 0.001), and the distance from the tongue base to the soft palate (SM2; P < 0.001; 9% CI, 1.8 × 10-4, 3.9 × 10-4; ρ = 0.85, P < 0.001). There were no significant relationships between age and AVC1 (P = 0.16) and SM1 (P = 0.44).

CONCLUSIONS

Airway ultrasound is a feasible tool to evaluate the pediatric airway in children younger than 10 years; however, the detection of age-related changes of certain structures is limited to select measurements.

Point of Care Ultrasound on Labor and Delivery

Point of care ultrasound (POCUS) in the field of obstetric anesthesiology, including cardiac, pulmonary, neuraxial, gastric, and airway ultrasound, can facilitate rapid diagnosis, management, and clinical decision-making surrounding common maternal peripartum comorbidities, and obstetric complications. Routine and proficient utilization of POCUS can ultimately aid in anesthesiologists' role as critical care physicians in the multidisciplinary practice on labor and delivery, with potential future research aiming to determine the potential impact on maternal morbidity and mortality.

Comparison of clinical methods to diagnose pediatric endobronchial intubation-A randomized controlled trial

Background and Aims:

Diagnosing accurate placement of the tip of the endotracheal tube is crucial in pediatric practice. This study was conducted to find out the efficacy of five clinical methods to ascertain the tube position by a resident anesthesiologist.

Material and Methods:

This was a randomized crossover study conducted in a research institute. Fifty pediatric patients were enrolled. All patients were randomly allocated to tracheal (group T) or bronchial group (group B). The five clinical methods which were evaluated include the auscultation, observation of chest movements, bag compliance, tube depth, and capnography. In group T, the tube was placed in the trachea and later positioned in bronchus (assisted by fiberoptic bronchoscopy). The vice versa was done in group B. In each position, a single test followed by all tests was performed and after the change of position, the same single test followed by all tests was performed. Correct and incorrect diagnoses by tests in detecting tube positions were made and their sensitivity and odds ratio were estimated.

Results:

The tube depth and combination of all tests detected endobronchial intubation with a sensitivity of 88% and 97%, respectively, which is more than that of auscultation (70%) and observation (55%). Evaluation of the difference in agreement level of tube depth to detect tube-position showed the odds ratio of 2.28 (0.17–30.95) for detecting endobronchial intubation.

Conclusion:

We observed that the tube-depth was better than the other individual tests in diagnosing endobronchial intubation in pediatric patients. However, its efficacy is lesser than that of performing all clinical tests together.

Bedside Ultrasound for Procedural Assistance in Pediatrics

Point-of-care ultrasound (POCUS) is a noninvasive imaging tool with both diagnostic and therapeutic applications. In this article, the author will review the role of POCUS for vascular access, endotracheal intubation, lumbar puncture, chest tube, and diagnosing coronavirus disease 2019 lung pathology. This will include a review of the evidence, technique, and strategies for optimizing performance of these procedures. [Pediatr Ann. 2021;50(10):e404-e410.].

Assessing the accuracy of ultrasound measurements of tracheal diameter: an in vitro experimental study

Background

Recent studies indicate that ultrasound can detect changes in tracheal diameter during endotracheal tube (ETT) cuff inflation. We sought to assess the accuracy of ultrasound measurement of tracheal diameter, and to determine the relationship between tracheal wall pressure (TWP), cuff inflation volume (CIV), and the degree of tracheal deformation.

Methods

Our study comprised two parts: the first included 45 porcine tracheas, the second 41 porcine tracheas. Each trachea was intubated with a cuffed ETT, which was connected to an injector and the manometer via a three-way tap. The cuff was inflated and the cuff pressure recorded before and after intubation. The tracheal diameter was measured using ultrasound. This included three separate measurements: outer transverse diameter (OTD), internal transverse diameter (ITD), and anterior tracheal wall thicknesses (ATWT). A precision electronic Vernier caliper was also used to measure tracheal diameter. We calculated TWP and the percentage change of tracheal diameter. The Bland–Altman method, linear regression, and locally weighted regression (LOESS) were used to analyze the data.

Results

There were strong correlation and agreement for OTD (r = 0.97, P < 0.001) and ITD (r = 0.90, P < 0.001) as measured by ultrasound and by precision electronic Vernier caliper, but a poor correlation for ATWT (r = 0.58, P < 0.001). There was a strong correlation between the percentage change of OTD (OTD%, r = 0.75, P < 0.001) and CIV, the percentage change of ITD (ITD%, r = 0.77, P < 0.001) and CIV, TWP (r = 0.75, P < 0.001) and CIV. And a strong correlation was also found between TWP and OTD% (r = 0.84, P < 0.001), TWP and ITD% (r = 0.84, P < 0.001).

Conclusions

Use of ultrasound to measure OTD and ITD is accurate, but is less accurate for ATWT. There is a close correlation between OTD%, ITD%, CIV and TWP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01398-3.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Evaluation of a survey for acute care programme directors on the utilisation of point-of-care ultrasound

PURPOSE

Point-of-care ultrasound (POCUS) is ultrasound brought to the patient's bedside and performed in 'real time' by the healthcare provider. The utility of POCUS to facilitate management of the acutely ill patient has been demonstrated for multiple pathologies. However, the integration of ultrasonography and echocardiography training into residency curriculum varies across the acute care specialties.

STUDY DESIGN

After an institutional review board approval, anaesthesiology, emergency medicine, family medicine, internal medicine, paediatrics and general surgery programme directors (PDs) were surveyed. The survey consisted of 11 questions evaluating the primary bedside assessment tool for common acute care situations, POCUS topics that the PDs were comfortable practising and topics that the PDs felt were useful for their specialty. Barriers to POCUS use, certification and documentation were also surveyed.

RESULTS

Overall, 270 PD surveys were completed. The preferred primary assessment tool for common acute care situations varied with specialty; emergency medicine PDs consistently responded that POCUS was the diagnostic modality of choice (p<0.0001). The majority of the PDs reported lack of educational opportunities as the primary barrier to learning POCUS (64%). Most PDs indicated that POCUS examinations should be documented (95.7%), and 39% reported that departmental certification would be sufficient.

CONCLUSIONS

This study is the first to evaluate differences in the preferred initial bedside assessment tool between the acute care specialties. Although POCUS is a superior tool for evaluating acute pathologies, disconnect between education and utilisation remains. This study highlights the need to incorporate POCUS into the acute care specialty curriculum.

Perioperative Point-of-Care Ultrasound Use by Anesthesiologists

Point-of-Care ultrasound (POCUS) is the bedside utilization of ultrasound, in real-time, to aid in the diagnosis and treatment of patients. Image acquisition from POCUS utilization by anesthesiologists involves the assessment of multiple organs in different perioperative situations. POCUS can be utilized to enhance clinical decision-making in a variety of perioperative situations due to its ability to assess endotracheal tube placement, cardiac function, pulmonary function, aspiration risk, hemodynamics, vascular access, and nerve visualization for regional procedures. The mounting clinical evidence for the value of POCUS in perioperative settings, its growing affordability, and its low associated risks are responsible for the nationwide movement across many anesthesiology residency programs to increase the focus on perioperative ultrasound training. The purpose of this review is to present to current anesthesiologists and anesthesiology trainees, a broad discussion regarding the diverse utility and importance of POCUS in perioperative settings.

Ultrasonography for airway management

Ultrasonography (USG) allows a new approach to the airway in anaesthesia and intensive care. USG visualises the airway from the mouth to the lungs. By exploring the entire airway, USG proposes new criteria (1) to assess the risk of difficult laryngoscopy, (2) to anticipate the management of a difficult airway, (3) to confirm the position of the endotracheal tube (ETT), and (4) to confirm that the lungs are effectively ventilated. Intraoperatively, USG may also help to resolve acute ventilatory problems such as pneumothorax, delayed selective bronchial intubation after patient positioning (Trendelenburg, prone or lateral position) or acute pulmonary oedema.

Point of care airway ultrasound to select tracheal tube and determine insertion depth in cleft repair surgery

We aimed to evaluate the efficacy of using airway ultrasonography to select the correct tracheal tube size and insertion depth in pediatric patients who underwent cleft repair surgery as a way to decrease airway complications and adverse events during perioperative periods. Fifty-one patients (age < 28 months) were consecutively divided into conventional (n = 28) and ultrasound (n = 23) groups. Tracheal tube size and insertion depth were determined using the age-based formula and auscultation in the conventional group, whereas using ultrasonographic measurement of subglottic diameter with auscultation and lung ultrasonography in the ultrasound group. We evaluated the initially selected tube size, insertion depth, ventilatory indices, and the incidence of airway complications and adverse events. Tube insertion depth (median [interquartile range]) was significantly greater in the ultrasound group than in the conventional group (13.5 cm [12.5-14.0] vs 13.0 cm [11.8-13.0], P = 0.045). The number of complications and adverse events was significantly higher in the conventional group than in the ultrasound group (32.1% vs 4.3%, P = 0.013). Airway ultrasound application could reduce airway-related complications and adverse events by determining the appropriate tracheal tube size and insertion depth.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.

Point-of-Care Ultrasound, the New Musculoskeletal Physical Examination

ABSTRACT

The availability of handheld ultrasound offers physicians an opportunity to better define anatomy and pathophysiology, thus enhancing the diagnostic capabilities of a standard physical examination. The medical community increasingly embraces the potential for point-of-care ultrasound across medical specialties. The primary aim of this review was to identify and compile information on the current clinical utility of point-of-care ultrasound for musculoskeletal examination. This information will enable health care providers to understand the current utility and potential of musculoskeletal point-of-care ultrasound, thus facilitating its appropriate adoption into clinical practice.

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: Narrative Review

This review focuses on the current technique and evidence regarding the use of point-of-care ultrasound (POCUS) to evaluate lung isolation for thorax surgery in infants and children. Previous reports in infants and children are presented. Figures and high-quality video are used to demonstrate the technique for POCUS in pediatric patients and to highlight differences between pediatric and patients. Lung sliding in B-mode and the seashore sign in M-mode suggest that the lung is ventilated. Pediatric anesthesiologists should be familiar with this technique as it is non-invasive and may also be more accurate when compared with auscultation.

Perioperative Point-of-Care Ultrasound in Children

Anesthesiologists and other acute care physicians perform and interpret portable ultrasonography—point-of-care ultrasound (POCUS)—at a child’s bedside, in the perioperative period. In addition to the established procedural use for central line and nerve block placement, POCUS is being used to guide critical clinical decisions in real-time. Diagnostic point-of-care applications most relevant to the pediatric anesthesiologist include lung ultrasound for assessment of endotracheal tube size and position, pneumothorax, pleural effusion, pneumonia, and atelectasis; cardiac ultrasound for global cardiac function and hydration status, and gastric ultrasound for aspiration risk stratification. This article reviews and discusses select literature regarding the use of various applications of point-of-care ultrasonography in the perioperative period.

Unmasking the Lung Pulse for Detection of Endobronchial Intubation

The ultrasound lung pulse for detecting endobronchial intubation was first described in 2003 in the only study to date assessing its accuracy. It refers to rhythmic movement of the visceral pleura along the stationary parietal pleura as cardiac vibrations transmit through a motionless, airless lung. Compared to delayed visualization on chest radiography, this artifact immediately detects physiologic atelectasis. There is a scarcity of studies assessing the lung pulse, while several others that encountered this artifact did not even identify it. The lung pulse is useful for immediate detection of endobronchial intubation, but it remains unrecognized and underused by physicians.

Point-of-Care Ultrasound for Pediatric Endotracheal Tube Placement Confirmation by Advanced Practice Transport Nurses

OBJECTIVE

This study aimed to identify which point-of-care ultrasound (POCUS) techniques and sonographic signs were reliably acquired and interpreted by transport nurses for the confirmation of endotracheal tube placement in children.

METHODS

We developed and assessed a multimodal POCUS training curriculum for transport nurses that evaluated 5 sonographic signs using 3 scanning techniques.

RESULTS

Twenty-one transport nurses were enrolled in the curriculum. The mean scores (95% confidence interval [CI]) of the knowledge test were 82% (95% CI, 63%-93%), 88% (95% CI, 68%-95%), and 74% (95% CI, 53%-87%) for tracheal, lung, and hemidiaphragmatic scans, respectively. For the simulation image evaluation, 94% (95% CI, 77%-99%) of tracheal scan images, 97% (95% CI, 81%-99%) of lung scan images, and 88% (95% CI, 69%-96%) of hemidiaphragmatic scan images were determined clinically useful. For the pediatric intensive care unit image evaluation, 100% (95% CI, 86%-100%) of tracheal scan images, 100% (95% CI, 86%-100%) of lung scan images, and 79% (95% CI, 59%-91%) of hemidiaphragmatic scan images were determined clinically useful. A tracheal dilation sign was rarely captured by POCUS.

CONCLUSION

Transport nurses can acquire POCUS skills to confirm endotracheal tube placement in children. A combination of a double trachea sign, a lung sliding sign, and a lung pulse sign could be a feasible POCUS approach.

Lung sonography can improve the specificity of determination of left-sided double-lumen tracheal tube position in both novices and experts: a randomised prospective study

Objective

Lung sonography can be helpful to determine the position of a left-sided double-lumen tube (DLT). However, clinical experience is required for correct assessment. We investigated whether lung sonography can improve the diagnostic efficacy of determining the DLT position in novices and experts.

Methods

In this randomised prospective clinical study, 88 patients were allocated to two groups using auscultation or lung sonography for initial assessment of the DLT position. In each group, two repeated assessments were performed; the first was performed by a novice, and the second was performed by an expert. The final DLT position was confirmed by fibre-optic bronchoscopy. The primary outcome was the diagnostic efficacy (including overall accuracy, sensitivity, and specificity) in confirming the DLT position.

Results

In both the novices and experts, the specificity of determining the DLT position was significantly higher with lung sonography than auscultation (60.0% vs. 21.7% and 66.7% vs. 37.5%, respectively). Additionally, the predictability of an incorrect position was similar between the novices and experts using lung sonography (area under the curve of 0.665 and 0.690, respectively).

Conclusions

Lung sonography can improve the diagnostic efficacy of detecting an incorrect DLT position in both novices and experts.

Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management

Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review

Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.

In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.

Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.

Point-of-Care Ultrasound for Intubation Confirmation of COVID-19 Patients

The novel coronavirus disease of 2019 (COVID-19) is associated with significant morbidity and mortality, as well as large numbers of patients requiring endotracheal intubation. While much of the literature has focused on the intubation technique, there is scant discussion of intubation confirmation. Herein, we discuss the limitations of traditional confirmatory approaches, summarize the literature supporting a role for point-of-care ultrasound in this application, and propose an algorithm for intubation confirmation among COVID-19 patients.

Technologies to Optimize the Care of Severe COVID-19 Patients for Health Care Providers Challenged by Limited Resources

Health care systems are belligerently responding to the new coronavirus disease 2019 (COVID-19). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a specific condition, whose distinctive features are severe hypoxemia associated with (>50% of cases) normal respiratory system compliance. When a patient requires intubation and invasive ventilation, the outcome is poor, and the length of stay in the intensive care unit (ICU) is usually 2 or 3 weeks. In this article, the authors review several technological devices, which could support health care providers at the bedside to optimize the care for COVID-19 patients who are sedated, paralyzed, and ventilated. Particular attention is provided to the use of videolaryngoscopes (VL) because these can assist anesthetists to perform a successful intubation outside the ICU while protecting health care providers from this viral infection. Authors will also review processed electroencephalographic (EEG) monitors which are used to better titrate sedation and the train-of-four monitors which are utilized to better administer neuromuscular blocking agents in the view of sparing limited pharmacological resources. COVID-19 can rapidly exhaust human and technological resources too within the ICU. This review features a series of technological advancements that can significantly improve the care of patients requiring isolation. The working conditions in isolation could cause gaps or barriers in communication, fatigue, and poor documentation of provided care. The available technology has several advantages including (a) facilitating appropriate paperless documentation and communication between all health care givers working in isolation rooms or large isolation areas; (b) testing patients and staff at the bedside using smart point-of-care diagnostics (SPOCD) to confirm COVID-19 infection; (c) allowing diagnostics and treatment at the bedside through point-of-care ultrasound (POCUS) and thromboelastography (TEG); (d) adapting the use of anesthetic machines and the use of volatile anesthetics. Implementing technologies for safeguarding health care providers as well as monitoring the limited pharmacological resources are paramount. Only by leveraging new technologies, it will be possible to sustain and support health care systems during the expected long course of this pandemic.

Lung ultrasound in a respiratory pandemic

Australian hospitals have prepared for a major surge in patients due to the infectious respiratory pandemic COVID-19. In other nations, patient presentations have overwhelmed resources. Ultrasound has been shown to be an effective tool to exclude significant life-threats in resource poor settings. In this article, we will describe three lung ultrasound algorithms for the emergency diagnosis of patients presenting with respiratory symptoms during a COVID-19 pandemic: (i) LUSC19: lung ultrasound to assess the severity of COVID-19; (ii) LUSAC: lung ultrasound to exclude alternative causes of respiratory distress; and (iii) LUSI: lung ultrasound following intubation. We anticipate that emergency physicians will use these algorithms during the upcoming respiratory pandemic to rapidly determine the severity of COVID-19 infection, to seek and treat significant alternative diagnoses and ensure endotracheal intubation.

Point-of-care ultrasound in pediatric anesthesia: perioperative considerations

PURPOSE OF REVIEW

To review the perioperative applications of point-of-care ultrasound (POCUS).

RECENT FINDINGS

The role of point-of-care ultrasonography for perioperative care is expanding with respect to perioperative application. The imaging approach can complement the physical exam and provide additional information for decision-making in pediatric perioperative medicine. This review will focus on applications in the following organ systems: airway, cardiac, pulmonary and gastric. Specifically, POCUS of the airway has been used to optimize endotracheal tube depth, aid in tube size selection and predict difficulty with laryngoscopy and intubation. Lung POCUS has been used to assess for causes hypoxemia as well as to optimize ventilatory mechanics. Cardiac POCUS has been used for assessment of hemodynamics, valvular and ventricular function. Gastric ultrasound has emerged as an evaluative mechanism of gastric content in the setting of fasting as well as to confirm placement of gastric tubes. The applications of POCUS in the perioperative setting continue to evolve as a reliable diagnostic tool that can assist in timely diagnosis, improve procedural safety and has the potential to improve patient outcomes.

SUMMARY

The utility of perioperative POCUS has been well demonstrated, specifically for examination of the airway, stomach and cardiopulmonary system. It is advisable for the novice sonographer to perform POCUS within the guidelines set by the American Society of Echocardiography regarding basic POCUS. As with all diagnostic modalities, understanding the limitations of ultrasound and POCUS as well as continuous self-assessment is crucial.

Relationship Between Evaluations of Tracheal Tube Position Using Ultrasound and Fluoroscopy in an Infant and Pediatric Population

Introduction: A non-radiographic technique to measure the location of the tracheal tube (TT) in children is of value given the risk of inappropriate TT placement along with concerns about radiation exposure. Airway point-of-care ultrasound (POCUS) has demonstrated utility in children, but the examinations vary by age and may require non-traditional techniques or utilize less common probes. This study evaluated the performance of measuring the tracheal location of the cuffed TT using a novel, linear probe-based POCUS examination over a wide age range of children. After adjusting for the subjects’ height and TT size, ultrasound measurements of the TT cuff location were compared with fluoroscopy measurements of the TT tip location. Methods: Perioperative pediatric patients (<10 years) requiring a cuffed TT were enrolled. After routine TT placement, ultrasound and fluoroscopy images were obtained. Measurements from the TT cuff to the cricoid cartilage were obtained from the POCUS examination. Chest fluoroscopy was reviewed to measure the TT’s distance from the carina. Both measurements were then compared after scaling for patient height. The duration of the ultrasound examination and image quality scores were also recorded. Results: Forty-one patients were enrolled, with a median age of 3 (25th/75th percentile: 1.50/7.00) years. The POCUS examination identified the TT cuff in all cases with the highest image quality score. The median POCUS exam time was 112 (25th/75th percentile: 80.00/156.00) seconds. There was a strong correlation between the POCUS measurements and the fluoroscopy measurements, r = −0.7575, 95% CI [−0.8638, −0.5866 ], p < 0.001). Conclusions: Our results demonstrate a strong correlation between POCUS TT localization measurements and traditional measurements via fluoroscopy. This study further supports the utility of POCUS for pediatric care.

Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice

Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.

Ultrasound versus manipulation to determine an intercostal space for single-port thoracoscopy surgery: a diagnostic accuracy study

Background

Malposition of the intercostal space used for single-port thoracoscopy surgery can lead to problems. This study was to assess the accuracy of point-of-care ultrasound in verifying the position of intercostal space.

Methods

A total of 200 patients, ASA (American Society of Anesthesiologists) physical status I or II, who underwent single-port thoracoscopic lobectomy, were enrolled. After the induction of anesthesia, a thoracic team confirmed the incision position. Firstly, the intercostal space was located by a young resident thoracic surgeon by ultrasound. Secondly, the intercostal space was located by an experienced thoracic surgeon by manipulation. Finally, the investigator verified the location of the intercostal space under direct vision through thoracoscopy, which was recognized as standard method. The time required by ultrasound and manipulation were recorded.

Results

The inter-relationships between ultrasound and the standard method and between manipulation and the standard method were consistent. Manipulation positioning showed a sensitivity of 90.6% and specificity of 30% while ultrasound positioning showed a sensitivity of 87.1% and specificity of 60%. The specificity of ultrasound positioning was higher than that of manipulation position. The time required by ultrasound was shorter than that required by manipulation.

Conclusions

Compared with the manipulation method, the ultrasound-guided method could accurately locate the intercostal space. Ultrasound requires less time than manipulation.

Trial registration

ISRCTN10722758. Registered 04 June 2019