Accuracy of a novel ultrasound technique for confirmation of endotracheal intubation by expert and novice emergency physicians

Michael Gottlieb, John M Bailitz, Errick Christian, Frances M Russell, Robert R Ehrman, Basem Khishfe, Alexander Kogan, Christopher Ross, Michael Gottlieb, John M Bailitz, Errick Christian, Frances M Russell, Robert R Ehrman, Basem Khishfe, Alexander Kogan, Christopher Ross

Abstract

Introduction: Recent research has investigated the use of ultrasound (US) for confirming endotracheal tube (ETT) placement with varying techniques, accuracies, and challenges. Our objective was to evaluate the accuracy of a novel, simplified, four-step (4S) technique.

Methods: We conducted a blinded, randomized trial of the 4S technique utilizing an adult human cadaver model. ETT placement was randomized to tracheal or esophageal location. Three US experts and 45 emergency medicine residents (EMR) performed a total of 150 scans. The primary outcome was the overall sensitivity and specificity of both experts and EMRs to detect location of ETT placement. Secondary outcomes included a priori subgroup comparison of experts and EMRs for thin and obese cadavers, time to detection, and level of operator confidence.

Results: Experts had a sensitivity of 100% (95% CI = 72% to 100%) and specificity of 100% (95% CI = 77% to 100%) on thin, and a sensitivity of 93% (95% CI = 66% to 100%) and specificity of 100% (95% CI = 75% to 100%) on obese cadavers. EMRs had a sensitivity of 91% (95% CI = 69% to 98%) and of specificity 96% (95% CI = 76% to 100%) on thin, and a sensitivity of 100% (95% CI = 82% to 100%) specificity of 48% (95% CI = 27% to 69%) on obese cadavers. The overall mean time to detection was 17 seconds (95% CI = 13 seconds to 20 seconds, range: 2 to 63 seconds) for US experts and 29 seconds (95% CI = 25 seconds to 33 seconds; range: 6 to 120 seconds) for EMRs. There was a statistically significant decrease in the specificity of this technique on obese cadavers when comparing the EMRs and experts, as well as an increased overall time to detection among the EMRs.

Conclusion: The simplified 4S technique was accurate and rapid for US experts. Among novices, the 4S technique was accurate in thin, but appears less accurate in obese cadavers. Further studies will determine optimal teaching time and accuracy in emergency department patients.

Figures

Figure 1
Figure 1
Four Step (4S) Technique. ETT, Endotracheal tube
Figure 2
Figure 2
Transverse view of the tracheal air column (A) between the lobes of the thyroid gland (G).
Figure 3
Figure 3
Initial oblique view of the tracheal air column (A), thyroid gland (G), and collapsed esophagus (E) in the typical location between the trachea and carotid artery (C).
Figure 4
Figure 4
Contralateral oblique view assessing for a right-sided esophagus between the tracheal air column (A) and carotid artery (C). (G) thyroid gland.
Figure 5
Figure 5
Comparison of tracheal (Left) and esophageal (Right) intubations via the Four Step (4S) Technique. A, air column; G, thyroid gland; E, collapsed esophagus (E)
Figure 6
Figure 6
Instructor methods. ETT, endotracheal tube; EMR, emergency medicine residents; US, ultrasound

References

    1. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology. 1995;82(2):367–76.
    1. Mort TC. Unplanned tracheal extubation outside the operating room: a quality improvement audit of hemodynamic and tracheal airway complications associated with emergency tracheal reintubation. Anesth Analg. 1998;86(6):1171–6.
    1. Sayre MR, O’Connor RE, Atkins DL, et al. Part 2: Evidence evaluation and management of potential or perceived conflicts of interest: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S657–64.
    1. MacLeod BA, Heller MB, Gerard J, et al. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med. 1991;20(3):267–70.
    1. Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation. J Emerg Med. 2001;20(3):223–9.
    1. Takeda T, Tanigawa K, Tanaka H, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting. Resuscitation. 2003;56(2):153–7.
    1. Deiorio NM. Continuous end-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement is neither widely available nor consistently applied by emergency physicians. Emerg Med J. 2005;22(7):490–3.
    1. Sağlam C, Unlüer EE, Karagöz A. Confirmation of endotracheal tube position during resuscitation by bedside ultrasonography. Am J Emerg Med. 2013;31(1):248–50.
    1. Ma G, Davis DP, Schmitt J, et al. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med. 2007;32(4):405–7.
    1. Chou HC, Tseng WP, Wang CH, et al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. 2011;82(10):1279–84.
    1. Tsung JW, Fenster D, Kessler DO, et al. Dynamic anatomic relationship of the esophagus and trachea on sonography: implications for endotracheal tube confirmation in children. J Ultrasound Med. 2012;31(9):1365–70.
    1. Werner SL, Smith CE, Goldstein JR, et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. 2007;49(1):75–80.
    1. Park SC, Ryu JH, Yeom SR, et al. Confirmation of endotracheal intubation by combined ultrasonographic methods in the Emergency Department. Emerg Med Australas. 2009;21(4):293–7.
    1. Milling TJ, Jones M, Khan T, et al. Transtracheal 2-d ultrasound for identification of esophageal intubation. J Emerg Med. 2007;32(4):409–14.
    1. Muslu B, Sert H, Kaya A, et al. Use of sonography for rapid identification of esophageal and tracheal intubations in adult patients. J Ultrasound Med. 2011;30(5):671–6.
    1. Phelan M, Hagerty D. The oblique view: an alternative approach for ultrasound-guided central line placement. J Emerg Med. 2009;37(4):403–8.

Source: PubMed

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