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Point-of-Care Ultrasound of the Head and Neck in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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2
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Gomes SH, Miranda A, Pêgo JM, Costa PS, Correia-Pinto J. Ultrasound-Guided Selective Bronchial Intubation: A Feasibility Study in Pediatric Animal Model. Front Med (Lausanne) 2022; 9:869771. [PMID: 35783614 PMCID: PMC9240755 DOI: 10.3389/fmed.2022.869771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Selective one-lung ventilation used to optimize neonatal and pediatric surgical conditions is always a demanding task for anesthesiologists, especially during minimally invasive thoracoscopic surgery. This study aims to introduce an ultrasound-guided bronchial intubation and exclusion technique in a pediatric animal model. Methods Seven rabbits were anesthetized and airway ultrasound acquisitions were done. Results Tracheal tube progression along the trachea to the right bronchus and positioning of the bronchial blocker in the left bronchus were successfully done with consistent ultrasound identification of relevant anatomical structures. Conclusion The study provided a new application of ultrasound in airway management. More advanced experimental studies are needed since this technique has the potential for translation to pediatric anesthesia.
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Affiliation(s)
- Sara Hora Gomes
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s-PT Government Associate Laboratory, Braga, Portugal
- *Correspondence: Sara Hora Gomes,
| | - Alice Miranda
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s-PT Government Associate Laboratory, Braga, Portugal
| | - José Miguel Pêgo
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s-PT Government Associate Laboratory, Braga, Portugal
| | - Patrício S. Costa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s-PT Government Associate Laboratory, Braga, Portugal
| | - Jorge Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s-PT Government Associate Laboratory, Braga, Portugal
- Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
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3
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Ichihashi K, Nonaka K. Point-of-care ultrasound for children. J Med Ultrason (2001) 2022; 49:639-654. [DOI: 10.1007/s10396-021-01169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
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4
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Wani TM, John J, Rehman S, Bhaskar P, Sahabudheen AF, Mahfoud ZR, Tobias JD. Point-of-care ultrasound to confirm endotracheal tube cuff position in relationship to the cricoid in the pediatric population. Paediatr Anaesth 2021; 31:1310-1315. [PMID: 34608715 DOI: 10.1111/pan.14303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 08/14/2021] [Accepted: 09/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anatomically, the subglottic area and the cricoid ring are the narrowest portions of the larynx. To limit the potential for damage related to mucosal pressure injuries from the presence of an endotracheal tube, the cuff should be placed below the cricoid in children. Previously, no clinical or imaging method has been used in real time to determine the exact location of the endotracheal tube cuff after endotracheal intubation. Point-of-care ultrasound may provide an option as a safe and rapid means of visualizing the endotracheal tube cuff and its relationship to the cricoid ring thereby achieving ideal endotracheal tube cuff positioning-below the cricoid. METHODS In this prospective, nonrandomized trial, point-of-care ultrasound was used following endotracheal intubation in children to evaluate the position of the endotracheal tube cuff in relationship to the cricoid and tracheal rings. After anesthesia was induced and the trachea was intubated, the endotracheal tube cuff and its position in relation to the cricoid and tracheal rings were identified in the longitudinal plane using point-of-care ultrasound. With the patient's neck in a neutral position, the level of the proximal (cephalad) margin of the saline-filled cuff of the endotracheal tube was identified and recorded in relationship to the cricoid and tracheal rings. The ideal position is defined as the cephalad margin of the endotracheal tube cuff below the level of the cricoid. RESULTS The study cohort included 80 patients, ranging in age from 1 to 78 months. In all patients, the cuff of the ETT, cricoid, and tracheal rings were identified. The cephalad end of the endotracheal tube cuff was found at the level of the cricoid in 16.3% of patients, at the first tracheal ring in 27.5% of patients, at the second tracheal ring in 23.8% of patients, at the third tracheal ring in 17.5% of patients, and at below the fourth tracheal ring in 15% of patients. Initial endotracheal tube cuff position had no significant association with age, height, weight, endotracheal tube size, and endotracheal tube type. CONCLUSION Point-of-care ultrasound provides a rapid and effective means of identifying the position of the endotracheal tube cuff in relationship to the cricoid ring. The technique may have applications in the perioperative arena, emergency departments, and intensive care units.
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Affiliation(s)
- Tariq M Wani
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | - Jiju John
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | - Saif Rehman
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | | | | | - Ziyad R Mahfoud
- Department of Medical Education, Weill Cornell Medicine, Doha, Qatar.,Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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5
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The Role of Lung Ultrasound in the Management of the Critically Ill Neonate-A Narrative Review and Practical Guide. CHILDREN-BASEL 2021; 8:children8080628. [PMID: 34438519 PMCID: PMC8391155 DOI: 10.3390/children8080628] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022]
Abstract
Lung ultrasound makes use of artifacts generated by the ratio of air and fluid in the lung. Recently, an enormous increase of research regarding lung ultrasound emerged, especially in intensive care units. The use of lung ultrasound on the neonatal intensive care unit enables the clinician to gain knowledge about the respiratory condition of the patients, make quick decisions, and reduces exposure to ionizing radiation. In this narrative review, the possibilities of lung ultrasound for the stabilization and resuscitation of the neonate using the ABCDE algorithm will be discussed.
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6
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Zetlaoui PJ. Ultrasonography for airway management. Anaesth Crit Care Pain Med 2021; 40:100821. [PMID: 33722741 DOI: 10.1016/j.accpm.2021.100821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 10/31/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Paul J Zetlaoui
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Orsay, 48, Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.
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7
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Haskins SC, Bronshteyn Y, Perlas A, El-Boghdadly K, Zimmerman J, Silva M, Boretsky K, Chan V, Kruisselbrink R, Byrne M, Hernandez N, Boublik J, Manson WC, Hogg R, Wilkinson JN, Kalagara H, Nejim J, Ramsingh D, Shankar H, Nader A, Souza D, Narouze S. 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. Reg Anesth Pain Med 2021; 46:1031-1047. [PMID: 33632778 DOI: 10.1136/rapm-2021-102560] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Yuriy Bronshteyn
- Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anahi Perlas
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Joshua Zimmerman
- Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcos Silva
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen Boretsky
- Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Chan
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Melissa Byrne
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nadia Hernandez
- Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan Boublik
- Anesthesiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - William Clark Manson
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rosemary Hogg
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Jonathan N Wilkinson
- Intensive Care and Anaesthesia, Northampton General Hospital, Northampton, Northamptonshire, UK
| | | | - Jemiel Nejim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Davinder Ramsingh
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Antoun Nader
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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8
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Kars MS, Gomez Morad A, Haskins SC, Boublik J, Boretsky K. Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review. Reg Anesth Pain Med 2020; 45:985-992. [DOI: 10.1136/rapm-2020-101341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 01/11/2023]
Abstract
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.
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9
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Chandnani HK, Maxson IN, Mittal DK, Dehom S, Moretti A, Dinh VA, Lopez M, Ejike JC. Endotracheal Tube Placement Confirmation with Bedside Ultrasonography in the Pediatric Intensive Care Unit: A Validation Study. J Pediatr Intensive Care 2020; 10:180-187. [PMID: 34395035 DOI: 10.1055/s-0040-1715484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022] Open
Abstract
Critically ill patients who are intubated undergo multiple chest X-rays (CXRs) to determine endotracheal tube position; however, other modalities can save time, medical expenses, and radiation exposure. In this article, we evaluated the validity and interrater reliability of ultrasound to confirm endotracheal tube (ETT) position in patients. A prospective study was performed on intubated patients with cuffed ETTs. The accuracy of ultrasound to confirm correct ETT placement in 92 patients was 97.8%. Sensitivity, positive predictive value, and agreement of 97.7, 93.3, and 91.3% were found on comparing ultrasound to CXR findings. Ultrasound is feasible, reliable, and has good interrater reliability in assessing correct ETT position in children.
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Affiliation(s)
- Harsha K Chandnani
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Ivanna N Maxson
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Disha K Mittal
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Salem Dehom
- Graduate Department, Loma Linda University School of Nursing, Loma Linda, California, United States
| | - Anthony Moretti
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Vi A Dinh
- Department of Medicine and Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Merrick Lopez
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
| | - Janeth C Ejike
- Department of Pediatrics, Division of Pediatric Critical Care, Loma Linda University Children's Hospital, Loma Linda, California, United States
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10
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Breitkreutz R, Sladdin E, Geuting M, Schröder TC, Lindner D, Damjanovic D. Anterior neck and airway ultrasound procedures with emphasis on resuscitation plus video clips. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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Ultrasound guided tracheal intubation with a styleted tracheal tube in anticipated difficult airway. J Clin Monit Comput 2020; 35:285-287. [PMID: 32242286 DOI: 10.1007/s10877-020-00506-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
Ultrasonography is a simple, reliable, non-invasive technique which helps in real-time assessment of airway anatomy and contributes to safer airway management in various settings like operating rooms, intensive care units and emergency departments. It also helps us to plan the appropriate anesthetic technique especially in difficult airway cases. Here, we discuss the importance of styleted tracheal tube in improving the accuracy of ultrasound guided tracheal intubation in anticipated difficult airway.
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13
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Elshazly AMAE, Motlb EAAM, Ghaffar NG. Re-intubation frequency in paediatric surgical patients : a randomised controlled trial. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.5.2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Orhan-Sungur M, Altun D, Özkan-Seyhan T, Aygün E, Koltka K, Çamcı E. Learning curve of ultrasound measurement of subglottic diameter for endotracheal tube selection in pediatric patients. Paediatr Anaesth 2019; 29:1194-1200. [PMID: 31583796 DOI: 10.1111/pan.13751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endotracheal tube size can be predicted according to ultrasound measurement of subglottic airway diameter. The learning curve for this method is not yet established. The aim was to evaluate the learning curve of anesthesiology residents in ultrasound measurement of subglottic airway diameter for prediction of endotracheal tube size using cumulative sum analysis. METHODS Sixteen anesthesiology residents measured transverse subglottic airway diameter in children undergoing general anesthesia with cuffed endotracheal intubation. Each resident performed 30 ultrasound examinations. Primary outcome was the successful prediction of endotracheal tube size according to ultrasound measurement. Cumulative sum analysis was performed with acceptable and unacceptable failure rates set as 20 and 40%, respectively. RESULTS Ten out of 16 residents (62.5%) were deemed successful as they were able to pass lower decision boundary, whereas six residents' CUSUM scores were between the decisions lines deeming them indeterminate. The overall success rate for determining the correct endotracheal tube size was 77.5%. Median number of attempts to cross lower decision boundary was 29 with minimum of 18 and maximum of 29 attempts among successful residents. CONCLUSION Learning curves constructed with cumulative sum analysis in this study showed that only 62.5% of residents were able to correctly predict cuffed endotracheal tube size with 80% success rate. Considerable variability in achieving competency necessitates objective follow-up of individual improvement.
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Affiliation(s)
- Mukadder Orhan-Sungur
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Demet Altun
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tülay Özkan-Seyhan
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Elif Aygün
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kemalettin Koltka
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Emre Çamcı
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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15
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Lun HM, Zhu SY, Hu Q, Liu YL, Wei LS. Sonographic Assessment of Oropharynx Movement During Deep Breathing. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2906-2914. [PMID: 31474385 DOI: 10.1016/j.ultrasmedbio.2019.07.680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 06/10/2019] [Accepted: 07/29/2019] [Indexed: 06/10/2023]
Abstract
To investigate the feasibility of ultrasonography in detecting the oropharynx movement during deep breathing and to quantitatively analyze oropharynx airway lumen changes during deep breathing. The motions of oropharynx were monitored, and sonographic measurements of airway lumen were obtained during deep breathing in 448 healthy volunteers. Adequate visualization of oropharynx movement was obtained on all healthy volunteers. The anterior-posterior (AP) diameters and AP/transverse (T) diameter ratios were greater at the end of deep inspiration than that at the end of deep expiration for each sex (p < 0.01). The anterior-posterior dimensional changes were greater than lateral airway dimensional changes each sex (p < 0.05). Ultrasonography could provide realistic impression of the process on the oropharynx movement during deep breathing and perform the quantitative analysis of the oropharynx airway lumen changes during deep breathing. The results were encouraging and supported the utility of ultrasonography in future studies.
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Affiliation(s)
- Hai-Mei Lun
- Department of Diagnostic Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shang-Yong Zhu
- Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| | - Qiao Hu
- Department of Diagnostic Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yao-Li Liu
- Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Li-Si Wei
- Department of Diagnostic Ultrasound, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Fraga MV, Stoller JZ, Glau CL, De Luca D, Rempell RG, Wenger JL, Yek Kee C, Muhly WT, Boretsky K, Conlon TW. Seeing Is Believing: Ultrasound in Pediatric Procedural Performance. Pediatrics 2019; 144:peds.2019-1401. [PMID: 31615954 DOI: 10.1542/peds.2019-1401] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2019] [Indexed: 11/24/2022] Open
Abstract
Point-of-care ultrasound is currently widely used across the landscape of pediatric care. Ultrasound machines are now smaller, are easier to use, and have much improved image quality. They have become common in emergency departments, ICUs, inpatient wards, and outpatient clinics. Recent growth of supportive evidence makes a strong case for using point-of-care ultrasound for pediatric interventions such as vascular access (in particular, central-line placement), lumbar puncture, fluid drainage (paracentesis, thoracentesis, pericardiocentesis), suprapubic aspiration, and soft tissue incision and drainage. Our review of this evidence reveals that point-of-care ultrasound has become a powerful tool for improving procedural success and patient safety. Pediatric patients and clinicians performing procedures stand to benefit greatly from point-of-care ultrasound, because seeing is believing.
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Affiliation(s)
| | | | - Christie L Glau
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit, Institut National de la Santé et de la Recherche Médicale U999, South Paris-Saclay University, Paris, France
| | | | - Jesse L Wenger
- Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Chor Yek Kee
- Department of Pediatrics, Sarawak General Hospital, Sarawak, Malaysia; and
| | - Wallis T Muhly
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen Boretsky
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts
| | - Thomas W Conlon
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mori T, Nomura O, Hagiwara Y, Inoue N. Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2945-2954. [PMID: 30993739 DOI: 10.1002/jum.15000] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/25/2019] [Accepted: 03/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. METHODS This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. RESULTS In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). CONCLUSION The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yusuke Hagiwara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nobuaki Inoue
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
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Ahn J, Kwon E, Lee S, Hahm T, Jeong J. Ultrasound-guided lung sliding sign to confirm optimal depth of tracheal tube insertion in young children. Br J Anaesth 2019; 123:309-315. [DOI: 10.1016/j.bja.2019.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022] Open
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Current Concepts in the Management of the Difficult Pediatric Airway. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00319-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sethi AK, Salhotra R, Chandra M, Mohta M, Bhatt S, Kayina CA. Confirmation of placement of endotracheal tube - A comparative observational pilot study of three ultrasound methods. J Anaesthesiol Clin Pharmacol 2019; 35:353-358. [PMID: 31543584 PMCID: PMC6748007 DOI: 10.4103/joacp.joacp_317_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Confirmation of endotracheal tube (ETT) position is necessary to ensure proper ventilation. The present study was conducted with the aim to compare the efficacy of three ultrasonographic (USG) techniques in terms of time taken for confirmation of ETT position. The time taken by each USG technique was also compared with that for auscultation and capnography. The ability of the three USG techniques to identify tracheal placement of ETT was evaluated in all patients. Material and Methods Ninety adult American Society of Anesthesiologists (ASA) I/II patients requiring general anaesthesia with tracheal intubation were randomised into three groups (n = 30 each) depending upon the initial USG transducer position used to confirm tracheal placement of ETT: group T (tracheal), group P (pleural) and group D (diaphragm). The time taken for confirmation of tracheal placement of ETT by USG, auscultation and capnography was recorded for each of the groups. Subsequently, USG confirmation of ETT placement was performed with the other two USG techniques in all patients. Results The time taken for USG in group T was significantly less (3.8 ± 0.9 s) compared to group P (12.1 ± 1.6 s) and group D (13.8 ± 1.7 s); P < 0.001. USG was significantly faster than both auscultation and capnography in group T (P < 0.001), whereas in group P and group D, USG took longer time compared to auscultation (P = 0.014 and P < 0.001, respectively) but lesser time than capnography (P < 0.001 in both groups). Conclusion USG is a rapid technique for identification of ETT placement. All the three USG techniques are reliable in identifying the tracheal placement of ETT.
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Affiliation(s)
- Ashok K Sethi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Rashmi Salhotra
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Monika Chandra
- Department of Anaesthesiology, Maulana Azad Medical College and LN Hospital, Delhi, India
| | - Medha Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Shuchi Bhatt
- Department of Radiodiagnosis, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Choro A Kayina
- Department of Anaesthesiology, All India Institute of Medical Sciences, Delhi, India
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Abstract
OBJECTIVES Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation. METHODS A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience. RESULTS During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location. CONCLUSION Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.
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Lages N, Vieira D, Dias J, Antunes C, Jesus T, Santos T, Correia C. Acesso às vias aéreas guiado por ultrassom. Braz J Anesthesiol 2018; 68:624-632. [DOI: 10.1016/j.bjan.2018.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/06/2018] [Accepted: 06/22/2018] [Indexed: 01/17/2023] Open
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Gómez-López L, Torres B, Bergé R, Aguirre O, Luis M, Sala-Blanch X. Ultrasound measurement of anatomical parameters of the upper airway in adults. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:495-503. [PMID: 30031540 DOI: 10.1016/j.redar.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/28/2018] [Accepted: 05/30/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Most of the works on ultrasound airway anatomy are limited to a morphological description. A study was conducted in order to provide an objective normal range of measurements. MATERIALS AND METHODS Observational study to describe the ultrasound characteristics of the upper airway in adults without clinical difficult airway criteria, compared to cadaver dissection anatomical models. RESULTS The study included 45 volunteers (27 men and 18 women), and 3fresh cadavers. The quality of the examination was very good/good in 93% of the cases. MEASUREMENTS tracheal diameter (1.3±0.3cm), vocal cord (1.6±0.5cm), cricothyroid membrane (0.94±0.32cm), cricotracheal membrane (0.3±0.09cm), thickness of the muscles in the floor of the mouth (MFM) (1.5±0.26cm), sub-mandibular subcutaneous fat plus MFM (2.11±0.34cm), hyoid-mandible distance (5.35±0.69cm), palate-floor of the mouth distance (4.92±0.5cm), palate-anterior border of the mandible (5.51±0.7cm), and palate-pharynx angle (114±14). Observed differences: Males had a larger tracheal diameter than females (M: 1.4±0.3 vs. F: 1.2±0.2cm, p=0.014). Subject height showed a significant correlation with the tracheal diameter (R: 0.501, p<0.001), as well as the length of the vocal cord (R: 0.363, p=0.016), the thickness of MFM (R=0.299, p=0.046) as well as the hyoid-mandible (R: 0.556; p<0.001) and palate-mandible distances (R: 0.362; p=0.015). CONCLUSIONS Ultrasound allows the anatomy of upper airway to be evaluated, as well as to calculate distances between the anatomical structures. The study defines these distances in adult volunteers without clinical difficult airway criteria.
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Affiliation(s)
- L Gómez-López
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - B Torres
- Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | - R Bergé
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - O Aguirre
- Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | - M Luis
- Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - X Sala-Blanch
- Hospital Clínic de Barcelona, Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, España.
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Lages N, Vieira D, Dias J, Antunes C, Jesus T, Santos T, Correia C. [Ultrasound guided airway access]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 68. [PMID: 30245096 PMCID: PMC9391688 DOI: 10.1016/j.bjane.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Ultrasound has increasingly growing applications in anesthesia. This procedure has proven to be a novel, non-invasive and simple technique for the upper airway management, proving to be a useful tool, not only in the operating room but also in the intensive care unit and emergency department. Indeed, over the years mounting evidence has showed an increasing role of ultrasound in airway management. In this review, the authors will discuss the importance of ultrasound in the airway preoperative assessment as a way of detecting signs of difficult intubation or to define the type and/or size of the endotracheal tube as well as to help airway procedures such as endotracheal intubation, cricothyrotomy, percutaneous tracheal intubation, retrograde intubation as well as the criteria for extubation.
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Affiliation(s)
- Neusa Lages
- Centro Hospitalar do Alto Ave, Guimarães, Portugal,Corresponding author.
| | - Diana Vieira
- Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Joana Dias
- Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | | | - Tiago Jesus
- Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Telmo Santos
- Centro Hospitalar Trás Montes e Alto Douro, Vila Real, Portugal
| | - Carlos Correia
- Centro Hospitalar Trás Montes e Alto Douro, Vila Real, Portugal
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Gonzalez LK, Yellin S, Arroyo AC. Point-of-Care Ultrasound in the Pediatric Emergency Department: Where We're at, Where We're Going. Adv Pediatr 2018; 65:121-142. [PMID: 30053920 DOI: 10.1016/j.yapd.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Laura K Gonzalez
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA
| | - Sharon Yellin
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USA
| | - Alexander C Arroyo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA.
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Clifford M, Butt W. Tracheal tube insertion is an essential part of modern paediatric anaesthesia and critical care: let us get it right. Br J Anaesth 2018; 116:582-4. [PMID: 27106959 DOI: 10.1093/bja/aew103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Clifford
- Department of Anaesthesia and Pain Management Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - W Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
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Images in Anesthesiology: Point-of-care Ultrasound to Diagnose Esophageal Intubation. Anesthesiology 2018; 129:190. [DOI: 10.1097/aln.0000000000002146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mishra PR, Bhoi S, Sinha TP. Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation. J Emerg Trauma Shock 2018; 11:92-97. [PMID: 29937637 PMCID: PMC5994849 DOI: 10.4103/jets.jets_56_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction: Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation. Methods: It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were divided into ultrasonography (USG) and clinical examination (CE) arm. The objectives were to study the utility of POCUS in endotracheal tube placement and confirmations and identification of potentially fatal conditions as tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathology, pneumothorax, and others during RSI. Patient >1 year of age were included. Time taken for procedure, number of incorrect intubations, and pathologies detected were noted. The data were collected in Microsoft Excel spread sheets and analyzed using Stata (version 11.2, Stata Corp, Texas, U. S. A) software. Results: One hundred and six patients were recruited. The mean time for primary survey USG versus CE arm was (20 ± 10.01 vs. 18 ± 11.03) seconds. USG detected four pneumothorax, one tracheal injury, and one paratracheal hematoma. The mean procedure time USG versus CE arm was (37.3 ± 21.92 vs. 58 ± 32.04) seconds. Eight esophageal intubations were identified in USG arm by POCUS and two in CE arm by EtCO2 values. Conclusion: Integration of POCUS was useful in all three phases of RSI. It identified paratracheal hematoma, tracheal injury, and pneumothorax. It also identified esophageal intubation and confirmed main stem tracheal intubation in less time compared to five-point auscultation and capnography.
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Affiliation(s)
- Prakash Ranjan Mishra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Moustafa MA, Arida EA, Zanaty OM, El-tamboly SF. Endotracheal intubation: ultrasound-guided versus fiberscope in patients with cervical spine immobilization. J Anesth 2017; 31:846-851. [DOI: 10.1007/s00540-017-2410-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 09/01/2017] [Indexed: 11/30/2022]
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Point-of-care ultrasound utilizations in the emergency airway management: An evidence-based review. Am J Emerg Med 2017; 35:1202-1206. [DOI: 10.1016/j.ajem.2017.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/18/2022] Open
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Masoumi B, Azizkhani R, Emam GH, Asgarzadeh M, Kharazi BZ. Predictive Value of Tracheal Rapid Ultrasound Exam Performed in the Emergency Department for Verification of Tracheal Intubation. Open Access Maced J Med Sci 2017; 5:618-623. [PMID: 28932302 PMCID: PMC5591591 DOI: 10.3889/oamjms.2017.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/04/2017] [Accepted: 04/18/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Verification of the correct placement of the endotracheal tube (ETT) has been one of the most challenging issues of airway management in the field of emergency medicine. Early detection of oesophagal intubation through a reliable method is important for emergency physicians. AIM The aim of this study was to assess the diagnostic accuracy of tracheal rapid ultrasound exam (TRUE) to assess endotracheal tube misplacement during emergency intubation. METHODS This was an observational prospective study performed in the emergency department of the major tertiary referral hospital in the city. We included a consecutive selection of 100 patients. TRUE was performed for all these patients, and subsequently, quantitative waveform capnography was done. The later test is considered as the gold standard. RESULTS From our total 100 eligible patients, 93 (93%) participants had positive TRUE results (tracheal intubation) and 7 (7%) patients have negative TRUE results (esophageal intubation). Quantitative waveform capnography report of all 93 (100%) patients who had positive TRUE was positive (appropriate tracheal placement). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TRUE for detecting appropriate tracheal placement of ETT were 98.9% (95% CI, 93.3% to 99.8%), 100% (95% CI, 51.6% to 100%), 100% (95% CI, 95.1% to 100%) and 85.7% (95% CI, 42% to 99.2%) respectively. CONCLUSIONS Performing TRUE is convenient and feasible in many emergency departments and pre-hospital settings. We would recommend emergency units explore the possibility of using TRUE as a method in the assessment of proper ETT placement.
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Affiliation(s)
- Babak Masoumi
- Department of Emergency Medicine, Emergency Medicine Research Center, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Azizkhani
- Department of Emergency Medicine, Emergency Medicine Research Center, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gilava Hedayati Emam
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Asgarzadeh
- Chief Research Fellow, Harvard University, T.H. Chan School of Public Health, Massachusetts, USA
| | - Behrouz Zargar Kharazi
- Department of Emergency Medicine, Emergency Medicine Research Center, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Jaeel P, Sheth M, Nguyen J. Ultrasonography for endotracheal tube position in infants and children. Eur J Pediatr 2017; 176:293-300. [PMID: 28091777 DOI: 10.1007/s00431-017-2848-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/21/2016] [Accepted: 01/02/2017] [Indexed: 01/19/2023]
Abstract
UNLABELLED Ultrasonography (US) has been shown to be effective for verifying endotracheal tube (ETT) position in adults but has been less studied in infants and children. We review the literature regarding US for ETT positioning in the pediatric population. A literature search was conducted using the Ovid and MEDLINE databases with search terms regarding US relating to ETT intubation and positioning in infants and children. Most studies in neonates and infants used the midsagittal suprasternal view. Studies reported >80% visualization of the ETT tip by US, and US interpretation of the ETT position correlated with the XR position in 73-100% of cases. Studies of older children used the suprasternal views, substernal views, and mid-axillary intercostal views. US appears comparable to XR and capnography in determining ETT position in this population. CONCLUSION US for ETT verification appears to be well tolerated in infants and children and may augment determination of proper ETT position in combination with other ETT verification modalities. Further studies are needed regarding technique and training. What is Known: • Point-of-care ultrasonography is realizing increased availability and use in several pediatric specialties. • Ultrasonography has been shown to be effective for verifying ETT position in adults but have been less studied in infants and children. What is New: • Ultrasonography for endotracheal tube verification appears to be well tolerated in infants and children. • Ultrasonography may augment determination of proper endotracheal tube position in combination with other verification modalities such as radiography and capnography in the pediatric population.
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Affiliation(s)
- Pooja Jaeel
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mansi Sheth
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jimmy Nguyen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Center for Fetal and Neonatal Medicine, Division of Neonatal-Perinatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 1200 N. State Street-IRD-820, Los Angeles, CA, 90033, USA.
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Najib K, Pishva N, Amoozegar H, Pishdad P, Fallahzadeh E. Ultrasonographic confirmation of endotracheal tube position in neonates. Indian Pediatr 2016; 53:886-888. [DOI: 10.1007/s13312-016-0953-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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La ecografía pulmonar como herramienta para guiar la surfactación en neonatos prematuros. An Pediatr (Barc) 2016; 84:249-53. [DOI: 10.1016/j.anpedi.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/02/2015] [Accepted: 09/07/2015] [Indexed: 01/25/2023] Open
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Rodríguez-Fanjul J, Balcells Esponera C, Moreno Hernando J, Sarquella-Brugada G. Lung ultrasound as a tool to guide the administration of surfactant in premature neonates. An Pediatr (Barc) 2016. [DOI: 10.1016/j.anpede.2015.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Point-of-care ultrasonography in the detection of pediatric esophageal food impaction. Am J Emerg Med 2016; 34:763.e1-3. [DOI: 10.1016/j.ajem.2015.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 01/06/2023] Open
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Pérez-Quevedo O, López-Álvarez JM, Limiñana-Cañal JM, Loro-Ferrer JF. Design and application of model for training ultrasound-guided vascular cannulation in pediatric patients. Med Intensiva 2015; 40:364-70. [PMID: 26746125 DOI: 10.1016/j.medin.2015.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/19/2015] [Accepted: 11/21/2015] [Indexed: 01/31/2023]
Abstract
UNLABELLED Central vascular cannulation is not a risk-free procedure, especially in pediatric patients. Newborn and infants are small and low-weighted, their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter. These characteristics, together with the natural anatomical variability and poor collaboration of small children, make this technique more difficult to apply. Therefore, ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population. OBJECTIVE (a) To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients; (b) to ultrasound-guided vascular cannulation in the model. RESULTS The model consisted of two components: (a) muscular component: avian muscle, (b) vascular component: elastic tube-like structure filled with fluid. 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated, for two medical operators with different degree of experience. The average depth and diameter of vessel cannulated were 1.16 (0.42)cm and 0.43 (0.1)cm, respectively. The average number of attempts was of 1.22 (0.62). The percentage of visualization of the needle was 74%. The most frequent maneuver used for the correct location, was the modification of the angle of the needle and the relocation of the guidewire in 24% of the cases. The average time for the correct cannulations was 41 (35.8)s. The more frequent complications were the vascular perforation (11.9%) and the correct vascular puncture without possibility of introducing the guidewire (1.2%). The rate of success was 96%. CONCLUSIONS The model simulates the anatomy (vascular and muscular structures) of a pediatric patient. It is cheap models, easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation.
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Affiliation(s)
- O Pérez-Quevedo
- Unidad de Medicina Intensiva Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | - J M López-Álvarez
- Unidad de Medicina Intensiva Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain.
| | - J M Limiñana-Cañal
- Unidad de Investigación, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | - J F Loro-Ferrer
- Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Spain
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Garg R, Gupta A. Ultrasound: A promising tool for contemporary airway management. World J Clin Cases 2015; 3:926-929. [PMID: 26601094 PMCID: PMC4644893 DOI: 10.12998/wjcc.v3.i11.926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 07/21/2015] [Accepted: 09/28/2015] [Indexed: 02/05/2023] Open
Abstract
Airway evaluation and its management remains an ever emerging clinical science. Present airway management tools are static and do not provide dynamic airway management option. Visualized procedures like ultrasound (US) provide point of care real time dynamic views of the airway in perioperative, emergency and critical care settings. US can provide dynamic anatomical assessment which is not possible by clinical examination alone. US aids in detecting gastric contents and the nature of gastric contents (clear fluid, thick turbid or solid) as well. US can help in predicting endotracheal tube size by measuring subglottic diameter and diameter of left main stem bronchus. US was found to be a sensitive in detecting rotational malposition of LMA in children. Also, US is the fastest and highly sensitive tool to rule out a suspected intraoperative pneumothorax. In intensive care units, US helps torule out causes of inadequate ventilation, determine the tracheal width and distance from the skin to predict tracheotomy tube size and shape and assist with percutaneous dilatational tracheostomy. US can help in confirming the correct tracheal tube placement by dynamic visualisation of the endotracheal tube insertion, widening of vocal cords (children), and bilateral lung-sliding and diaphragmatic movement. Thus, ultrasonography has brought a paradigm shift in the practise of airway management. With increasing awareness, portability, accessibility and further sophistication in technology, it is likely to find a place in routine airway management. We are not far from the time when all of us will be carrying a pocket US machine like stethoscopes to corroborate our clinical findings at point of care.
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Chenkin J, McCartney CJL, Jelic T, Romano M, Heslop C, Bandiera G. Defining the learning curve of point-of-care ultrasound for confirming endotracheal tube placement by emergency physicians. Crit Ultrasound J 2015; 7:14. [PMID: 26383011 PMCID: PMC4573959 DOI: 10.1186/s13089-015-0031-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/26/2015] [Indexed: 11/10/2022] Open
Abstract
Background Unrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in the emergency department. Recent studies have demonstrated that point-of-care ultrasound (POCUS) may be a useful adjunct for confirming endotracheal tube placement; however, the amount of practice required to become proficient at this technique is unclear. The purpose of this study is to determine the amount of practice required by emergency physicians to become proficient at interpreting ultrasound video clips of esophageal and endotracheal intubations. Methods Emergency physicians and emergency medicine residents completed a baseline interpretation test followed by a 10 min online tutorial. They then interpreted POCUS clips of esophageal and endotracheal intubations in a randomly selected order. If an incorrect response was provided, the participant completed another practice session with feedback. This process continued until they correctly interpreted ten consecutive ultrasound clips. Descriptive statistics were used to summarize the data. Results Of the 87 eligible physicians, 66 (75.9 %) completed the study. The mean score on the baseline test was 42.9 % (SD 32.7 %). After the tutorial, 90.9 % (60/66) of the participants achieved proficiency after one practice attempt and 100 % achieved proficiency after two practice attempts. Six intubation ultrasound clips were misinterpreted, for a total error rate of 0.9 % (6/684). Overall, the participants had a sensitivity of 98.3 % (95 % CI 96.3–99.4 %) and specificity of 100 % (95 % CI 98.9–100 %) for detecting correct tube location. Scans were interpreted within an average of 4 s (SD 2.9 s) of the intubation. Conclusions After a brief online tutorial and only two practice attempts, emergency physicians were able to quickly and accurately interpret ultrasound intubation clips of esophageal and endotracheal intubations. Electronic supplementary material The online version of this article (doi:10.1186/s13089-015-0031-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jordan Chenkin
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Division of Emergency Medicine, University of Toronto, 2075 Bayview Avenue C753, Toronto, ON, M4N 3M5, Canada.
| | - Colin J L McCartney
- Department of Anesthesiology, University of Ottawa, Room B311, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON, K1Y 4E9, Canada.
| | - Tomislav Jelic
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Michael Romano
- Division of Emergency Medicine, University of Toronto, 2075 Bayview Avenue C753, Toronto, ON, M4N 3M5, Canada.
| | - Claire Heslop
- Division of Emergency Medicine, University of Toronto, 2075 Bayview Avenue C753, Toronto, ON, M4N 3M5, Canada.
| | - Glen Bandiera
- Division of Emergency Medicine, University of Toronto, 2075 Bayview Avenue C753, Toronto, ON, M4N 3M5, Canada. .,Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Hiruma M, Watanabe T, Baba H. Using lung ultrasound in an infant to detect bronchial intubation not previously identified by auscultation. Can J Anaesth 2015; 62:1121-2. [PMID: 25952564 DOI: 10.1007/s12630-015-0400-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/30/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- Masataka Hiruma
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan
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Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children. Resuscitation 2015; 89:8-12. [DOI: 10.1016/j.resuscitation.2014.08.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/08/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022]
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Chou EH, Dickman E, Tsou PY, Tessaro M, Tsai YM, Ma MHM, Lee CC, Marshall J. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation 2015; 90:97-103. [PMID: 25711517 DOI: 10.1016/j.resuscitation.2015.02.013] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to undertake a systematic review and meta-analysis to summarize evidence on the diagnostic value of ultrasonography for the assessment of endotracheal tube placement in adult patients. METHODS The major databases, PubMed, EMBASE, and the Cochrane Library, were searched for studies published from inception to June 2014. We selected studies that used ultrasonography to confirm endotracheal tube placement. The search was limited to human studies, and had no publication date or country restrictions. Exclusion criteria included case reports, comments, reviews, guidelines and animal studies. Two reviewers extracted and verified the data independently. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic (HSROC) curves, and bivariate random effect models. Meta-regression analysis was performed to explore the source of heterogeneity. The methodological quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTS A total of 12 eligible studies involving adult patients and cadaveric models were identified from 1488 references. For detection of esophageal intubation, the pooled sensitivity was 0.93 (95% CI: 0.86-0.96) and the specificity was 0.97 (95% CI: 0.95-0.98). The area under the summary ROC curve was 0.97 (95% CI: 0.95-0.98). The positive and negative likelihood ratios were 26.98 (95% CI: 19.32-37.66) and 0.08 (95% CI: 0.04-0.15), respectively. CONCLUSIONS Current evidence supports that ultrasonography has high diagnostic value for identifying esophageal intubation. With optimal sensitivity and specificity, ultrasonography can be a valuable adjunct in this aspect of airway assessment, especially in situations where capnography may be unreliable.
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Affiliation(s)
- Eric H Chou
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Eitan Dickman
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Po-Yang Tsou
- College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Mark Tessaro
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Yang-Ming Tsai
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - John Marshall
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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Gamble JJ, McKay WP, Wang AF, Yip KA, O'Brien JM, Plewes CE. Three-finger tracheal palpation to guide endotracheal tube depth in children. Paediatr Anaesth 2014; 24:1050-5. [PMID: 24958069 DOI: 10.1111/pan.12452] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Accurate endotracheal tube (ETT) depth is critical, especially in children. The current tools used to guide appropriate ETT depth have significant limitations. OBJECTIVES To evaluate the utility of tracheal palpation in the neck to guide appropriate ETT placement in children. METHODS A prospective observational study with a convenience sample of 50 children was conducted. During intubation, an investigator palpated the trachea with three fingertips side-by-side extending upward from the suprasternal notch. The anesthesiologist advanced the ETT slowly until palpated at the sternal notch. The investigator stated ETT palpation certainty as 'strongly felt', 'weakly felt', or 'not felt.' Final ETT position was determined by bronchoscopy and categorized as 'ETT too shallow' (tip in proximal ¼ of trachea), 'ETT too deep' (tip in distal ¼ of trachea), or 'ETT placement satisfactory' (between those extremes). RESULTS Thirty boys and 20 girls undergoing dental surgery with nasal intubation were recruited (median age 4.4 years; range 2.0-10.8). The ETT (all ≥4 mm ID) was palpable at the sternal notch in all patients: 46 of 50 strongly palpable and 4 of 50 weakly palpable. The experimental methods led to satisfactory ETT placement in 49 of 50 patients, too deep in 1 of 50 patients. Compared with the Pediatrics Advanced Life Support (PALS) predictive formula, satisfactory placement would have been 41 of 50 patients (P < 0.008). Number needed to treat is 6.3 for improvement over the PALS method. CONCLUSIONS The use of tracheal palpation to guide ETT placement has excellent clinical performance and better guides appropriate ETT depth than the PALS formula in our study population.
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Affiliation(s)
- Jonathan J Gamble
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, SK, Canada
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Parmar SB, Mehta HK, Shah NK, Parikh SN, Solanki KG. Ultrasound: A novel tool for airway imaging. J Emerg Trauma Shock 2014; 7:155-9. [PMID: 25114423 PMCID: PMC4126113 DOI: 10.4103/0974-2700.136849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 03/01/2014] [Indexed: 01/29/2023] Open
Abstract
Context: The scope of ultrasound is emerging in medical science, particularly outside traditional areas of radiology practice. Aims: We designed this study to evaluate feasibility of bedside sonography as a tool for airway assessment and to describe sonographic anatomy of airway. Settings and Design: A prospective, clinical study. Materials and Methods: We included 100 adult, healthy volunteers of either sex to undergo airway imaging systemically starting from floor of the mouth to the sternal notch in anterior aspect of neck by sonography. Results: We could visualize mandible and hyoid bone as a bright hyperechoic structure with hypoechoic acoustic shadow underneath. Epiglottis, thyroid cartilage, cricoid cartilage, and tracheal rings appeared hypoechoic. Vocal cords were visualized through thyroid cartilage. Interface between air and mucosa lining the airway produced a bright hyperechoic linear appearance. Artifacts created by intraluminal air prevented visualization of posterior pharynx, posterior commissure, and posterior wall of trachea. Conclusions: Ultrasound is safe, quick, noninvasive, repeatable, and bedside tool to assess the airway and can provide real-time dynamic images relevant for several aspects of airway management.
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Affiliation(s)
| | - Harshil Kirankumar Mehta
- Department of Emergency Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, Gujarat, India
| | - Nilima Kanaiyalal Shah
- Department of Emergency Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, Gujarat, India
| | - Samira Nayan Parikh
- Department of Emergency Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, Gujarat, India
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Kristensen MS, Teoh WH, Graumann O, Laursen CB. Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae. Insights Imaging 2014; 5:253-79. [PMID: 24519789 PMCID: PMC3999368 DOI: 10.1007/s13244-014-0309-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/20/2013] [Accepted: 01/10/2014] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To create a state-of-the-art overview of the new and expanding role of ultrasonography in clinical decision-making, intervention and management of the upper and lower airways, that is clinically relevant, up-to-date and practically useful for clinicians. METHODS This is a narrative review combined with a structured Medline literature search. RESULTS Ultrasonography can be utilised to predict airway difficulty during induction of anaesthesia, evaluate if the stomach is empty or possesses gastric content that poses an aspiration risk, localise the essential cricothyroid membrane prior to difficult airway management, perform nerve blocks for awake intubation, confirm tracheal or oesophageal intubation and facilitate localisation of tracheal rings for tracheostomy. Ultrasonography is an excellent diagnostic tool in intraoperative and emergency diagnosis of pneumothorax. It also enables diagnosis and treatment of interstitial syndrome, lung consolidation, atelectasis, pleural effusion and differentiates causes of acute breathlessness during pregnancy. Patient safety can be enhanced by performing procedures under ultrasound guidance, e.g. thoracocentesis, vascular line access and help guide timing of removal of chest tubes by quantification of residual pneumothorax size. CONCLUSIONS Ultrasonography used in conjunction with hands-on management of the upper and lower airways has multiple advantages. There is a rapidly growing body of evidence showing its benefits. TEACHING POINTS • Ultrasonography is becoming essential in management of the upper and lower airways. • The tracheal structures can be identified by ultrasonography, even when unidentifiable by palpation. • Ultrasonography is the primary diagnostic approach in suspicion of intraoperative pneumothorax. • Point-of-care ultrasonography of the airways has a steep learning curve. • Lung ultrasonography allows treatment of interstitial syndrome, consolidation, atelectasis and effusion.
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Affiliation(s)
- Michael S Kristensen
- Department of Anaesthesia, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100, Denmark,
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Ultrasound for the anesthesiologists: present and future. ScientificWorldJournal 2013; 2013:683685. [PMID: 24348179 PMCID: PMC3856172 DOI: 10.1155/2013/683685] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 09/26/2013] [Indexed: 12/13/2022] Open
Abstract
Ultrasound is a safe, portable, relatively inexpensive, and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine. Anesthesiologists encounter a variety of emergent situations and may benefit from the application of such a rapid and accurate diagnostic tool in their routine practice. This paper reviews current and potential applications of ultrasound in anesthesiology in order to encourage anesthesiologists to learn and use this useful tool as an adjunct to physical examination. Ultrasound-guided peripheral nerve blockade and vascular access represent the most popular ultrasound applications in anesthesiology. Ultrasound has recently started to substitute for CT scans and fluoroscopy in many pain treatment procedures. Although the application of airway ultrasound is still limited, it has a promising future. Lung ultrasound is a well-established field in point-of-care medicine, and it could have a great impact if utilized in our ORs, as it may help in rapid and accurate diagnosis in many emergent situations. Optic nerve sheath diameter (ONSD) measurement and transcranial color coded duplex (TCCD) are relatively new neuroimaging modalities, which assess intracranial pressure and cerebral blood flow. Gastric ultrasound can be used for assessment of gastric content and diagnosis of full stomach. Focused transthoracic (TTE) and transesophageal (TEE) echocardiography facilitate the assessment of left and right ventricular function, cardiac valve abnormalities, and volume status as well as guiding cardiac resuscitation. Thus, there are multiple potential areas where ultrasound can play a significant role in guiding otherwise blind and invasive interventions, diagnosing critical conditions, and assessing for possible anatomic variations that may lead to plan modification. We suggest that ultrasound training should be part of any anesthesiology training program curriculum.
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STEINMANN D, ENGEHAUSEN M, STILLER B, GUTTMANN J. Electrical impedance tomography for verification of correct endotracheal tube placement in paediatric patients: a feasibility study. Acta Anaesthesiol Scand 2013; 57:881-7. [PMID: 23750708 DOI: 10.1111/aas.12143] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endotracheal tubes (ETTs) are frequently used in paediatric anaesthesia. Correct placement is crucial. The aim of this study was to evaluate electrical impedance tomography (EIT) for guiding and confirmation of paediatric ETT placement. In a retrospective analysis of stored EIT data, distribution of ventilation between left and right lung was used to verify correct paediatric ETT placement. METHODS Left and right lung ventilation was studied by EIT in 18 paediatric patients (median age: 53 months) requiring anaesthesia and endotracheal intubation. EIT was recorded before induction of anaesthesia, during mask ventilation, during ETT placement (including deliberate mainstem intubation), and after ETT repositioning according to the formula: ETT intubation depth (cm) = 3× ETT internal diameter (mm) or the mainstem intubation method (withdrawing the ETT 2 cm). Final ETT position was confirmed by fluoroscopy. RESULTS Following deliberate mainstem intubation, distribution of ventilation to the right lung was unequivocally demonstrated by EIT. Homogeneous distribution of ventilation between left and right lung monitored with EIT correlated in each patient with correct endotracheal ETT placement. The distribution of left and right lung ventilation differed significantly (P < 0.05) between the initial two-lung ventilation and subsequent right one-lung ventilation, and between right one-lung and subsequent two-lung ventilation according to auscultation and the final ETT position, respectively. In one patient, ETT was misplaced within the oesophagus which was also obvious from the EIT record. CONCLUSION This study demonstrates that EIT enables non-invasive recognition of correct ETT placement. Homogeneous right-left-lung ventilation is an indicator for correct ETT placement.
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Affiliation(s)
- D. STEINMANN
- Department of Occupational Medicine; University Medical Center Freiburg; Freiburg; Germany
| | - M. ENGEHAUSEN
- Department of Anaesthesia and Critical Care Medicine; Ortenau Clinical Center; Offenburg; Germany
| | - B. STILLER
- Department of Congenital Heart Disease; University Heart Center Freiburg; Freiburg; Germany
| | - J. GUTTMANN
- Department of Anaesthesia and Critical Care Medicine; University Medical Center Freiburg; Freiburg; Germany
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Ingested foreign bodies: a case series demonstrating a novel application of point-of-care ultrasonography in children. Pediatr Emerg Care 2013; 29:870-3. [PMID: 23823272 DOI: 10.1097/pec.0b013e3182999ba3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In an era of recognizing the risks of radiation exposure, it is important to develop alternatives to radiographs. Bedside ultrasound has become an important adjunct to clinical diagnoses and procedural guidance in the emergency department. We present a case series of two patients who presented to a pediatric emergency department after witnessed coin ingestions. Point-of-care ultrasonography was able to accurately identify the location of each of the coins, at the thoracic inlet and in the stomach, as confirmed by chest radiography. To our knowledge, point-of-care ultrasonography has not been previously utilized to detect and localize esophageal foreign bodies in the emergency department.
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Abstract
Currently, the role of ultrasound (US) in anaesthesia-related airway assessment and procedural interventions is encouraging, though it is still ill defined. US can visualise anatomical structures in the supraglottic, glottic and subglottic regions. The floor of the mouth can be visualised by both transcutaneous view of the neck and also by transoral or sublinguial views. However, imaging the epiglottis can be challenging as it is suspended in air. US may detect signs suggestive of difficult intubation, but the data are limited. Other possible applications in airway management include confirmation of correct endotracheal tube placement, prediction of post-extubation stridor, evaluation of soft tissue masses in the neck prior to intubation, assessment of subglottic diameter for determination of paediatric endotracheal tube size and percutaneous dilatational tracheostomy. With development of better probes, high-resolution imaging, real-time picture and clinical experience, US has become the potential first-line noninvasive airway assessment tool in anaesthesia and intensive care practice.
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Affiliation(s)
- Pankaj Kundra
- Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Medical Education and Research, Pondicherry, India
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