PoCUS for ETT location

June 22nd, 2016

Davinder R, Ethan F, Robert H et al.

Auscultation versus Point-of-care Ultrasound to Determine Endotracheal versus Bronchial Intubation. A Diagnostic Accuracy Study

Anesthesiology 2016; 124:1012-20

 

There has been a tremendous amount of literature published over the past few years assessing the use of PoCUS for endotracheal tube placement.  Furthermore, the 2015 AHA guidelines have recommended that PoCUS can be used as a tool for assessing the location of the ETT. This study aimed to compare auscultation for PoCUS for endotracheal tube positioning.

This was an operating room based study performed by trained anesthesiologists. This was a double blinded, randomized study, with a very well described study protocol. Patients with an anticipated difficult airway or primary pulmonary pathologies were excluded.  After patients were successfully intubated, an “expert” anesthetist in fiber optic intubation, would then place the ETT based on the patients randomization. The ETT was placed in either the trachea, right or left mainstem bronchus. Blinding in this study was done well! The patients head was covered as not to reveal the ETT depth and the ventilator was covered as not to reveal airway pressures to study participants. A third anesthetist was then brought in to auscultate the chest to determine ETT position.   After that the PoCUS physician performed a lung ultrasound assessment looking for lung sliding and a tracheal ultrasound as well. The physicians performing the ultrasound assessment were well versed in their training, having done at least 50 scans in PoCUS and an additional 25 scans of the study based protocol.

 

The Results

A total of 42 patients were enrolled, with very similar baseline demographics. Auscultation showed a sensitivity of 66% (CI 0.39-0.87) and specificity of 59% (0.39-0.77). PoCUS showed a sensitivity of 93% (CI 0.66-1.00) and a specificity of 96% (0.79-0.99). The overall correct identification of tracheal or bronchial intubation was 62% in the auscultation group compared to 95% in the PoCUS group. The average time to complete the PoCUS assessment was 2 minutes and 42 seconds. It also carried a high interobserver agreement of a perfect 1.0.

 

The Bottom Line

This was a well designed study demonstrated the superiority of PoCUS for assessment of ETT depth/position compared to auscultation alone. While limitation included significant PoCUS operator experience, and exclusion of patients with difficult airways, this was a well done study that adds to our tool kit of assessing ETT position. With the ease of performing these scans, this is an ideal PoCUS scanning modality to learn that has immense potential in the emergency medicine or critical care settings. 

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