A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation

Osman Adi, Tan Wan Chuan, Manikam Rishya, Osman Adi, Tan Wan Chuan, Manikam Rishya

Abstract

Background: In emergency settings, verification of endotracheal tube (ETT) location is important for critically ill patients. Ignorance of oesophageal intubation can be disastrous. Many methods are used for verification of the endotracheal tube location; none are ideal. Quantitative waveform capnography is considered the standard of care for this purpose but is not always available and is expensive. Therefore, this feasibility study is conducted to compare a cheaper alternative, bedside upper airway ultrasonography to waveform capnography, for verification of endotracheal tube location after intubation.

Methods: This was a prospective, single-centre, observational study, conducted at the HRPB, Ipoh. It included patients who were intubated in the emergency department from 28 March 2012 to 17 August 2012. A waiver of consent had been obtained from the Medical Research Ethics Committee. Bedside upper airway ultrasonography was performed after intubation and compared to waveform capnography. Specificity, sensitivity, positive and negative predictive value and likelihood ratio are calculated.

Results: A sample of 107 patients were analysed, and 6 (5.6%) had oesophageal intubations. The overall accuracy of bedside upper airway ultrasonography was 98.1% (95% confidence interval (CI) 93.0% to 100.0%). The kappa value (Κ) was 0.85, indicating a very good agreement between the bedside upper airway ultrasonography and waveform capnography. Thus, bedside upper airway ultrasonography is in concordance with waveform capnography. The sensitivity, specificity, positive predictive value and negative predictive value of bedside upper airway ultrasonography were 98.0% (95% CI 93.0% to 99.8%), 100% (95% CI 54.1% to 100.0%), 100% (95% CI 96.3% to 100.0%) and 75.0% (95% CI 34.9% to 96.8%). The likelihood ratio of a positive test is infinite and the likelihood ratio of a negative test is 0.0198 (95% CI 0.005 to 0.0781). The mean confirmation time by ultrasound is 16.4 s. No adverse effects were recorded.

Conclusions: Our study shows that ultrasonography can replace waveform capnography in confirming ETT placement in centres without capnography. This can reduce incidence of unrecognised oesophageal intubation and prevent morbidity and mortality.

Trial registration: National Medical Research Register NMRR11100810230.

Figures

Figure 1
Figure 1
Tracheal intubation. The images show endotracheal intubation (ETT) in correct position, as seen in the horizontal view (I); the arrow indicates two hyper-echoic lines, which means the ETT is inside the trachea. On the vertical view (II), two symmetrical hyper-echoic lines indicate the ETT.
Figure 2
Figure 2
Oesophageal intubation. (a) US shows empty trachea. (b) Moving the probe to the left shows a dilated oesophagus. c. Focus on the oesophagus shows an endotracheal tube inside the oesophagus evidenced by two hyper-echoic lines inside oesophagus.
Figure 3
Figure 3
Study flow diagram.
Figure 4
Figure 4
Quantitative waveform capnography (ETCO2). The picture on the left shows a positive quantitative waveform capnography (ETCO2), which means ETT is in the trachea (correct placement). The picture on the right shows a negative ETCO2, which means ETT is not inside the trachea.

References

    1. Adriani J. Unrecognized esophageal placement of endotracheal tubes. South Med J. 1986;5(12):1591–1593. doi: 10.1097/00007611-198612000-00029.
    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;5(2):367–376. doi: 10.1097/00000542-199502000-00007.
    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;5(6):1171–1176.
    1. Vaghadia H, Jenkins LC, Ford RW. Comparison of end-tidal carbon dioxide, oxygen saturation and clinical signs for the detection of oesophageal intubation. Can J Anaesth. 1989;5(5):560–564. doi: 10.1007/BF03005386.
    1. Knapp S, Kofler J, Stoiser B, Thalhammer F, Burgmann H, Posch M, Hofbauer R, Stanzel M, Frass M. The assessment of four different methods to verify tracheal tube placement in the critical care setting. Anesth Analg. 1999;5(4):766–770.
    1. Bozeman WP, Hexter D, Liang HK, Kelen GD. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med. 1996;5(5):595–599. doi: 10.1016/S0196-0644(96)70162-2.
    1. Ma G, Davis DP, Schmitt J, Vilke GM, Chan TC, Hayden SR. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med. 2007;5(4):405–407. doi: 10.1016/j.jemermed.2006.08.023.
    1. Vukmir RB, Heller MB, Stein KL. Confirmation of endotracheal tube placement: a miniaturized infrared qualitative CO2 detector. Ann Emerg Med. 1991;5(7):726–729. doi: 10.1016/S0196-0644(05)80831-5.
    1. Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 2002;5(6):701–704. doi: 10.1007/s00134-002-1290-x.
    1. Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;5(5):497–503. doi: 10.1016/j.annemergmed.2004.09.014.
    1. Sustic A. Role of ultrasound in the airway management of critically ill patients. Crit Care Med. 2007;5(5 Suppl):S173–S177.
    1. Milling TJ, Jones M, Khan T, Tad-y D, Melniker LA, Bove J, Yarmush J, SchianodiCola J. Transtracheal 2-d ultrasound for identification of esophageal intubation. J Emerg Med. 2007;5(4):409–414. doi: 10.1016/j.jemermed.2006.08.022.
    1. Raphael DT, Conard FU III. Ultrasound confirmation of endotracheal tube placement. J Clin Ultrasound. 1987;5(7):459–462. doi: 10.1002/jcu.1870150706.
    1. Chou HC, Tseng WP, Wang CH, Ma MH, Wang HP, Huang PC, Sim SS, Liao YC, Chen SY, Hsu CY, Yen ZS, Chang WT, Huang CH, Lien WC, Chen SC. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. 2011;5(10):1279–84. doi: 10.1016/j.resuscitation.2011.05.016.
    1. Park SC, Ryu JH, Yeom SR, Jeong JW, Cho SJ. Confirmation of endotracheal intubation by combined ultrasonographic methods in the emergency department. Emerg Med Australas. 2009;5(4):293–297. doi: 10.1111/j.1742-6723.2009.01199.x.
    1. Kerrey BT, Geis GL, Quinn AM, Hornung RW, Ruddy RM. A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal tube position in a pediatric emergency department. Pediatrics. 2009;5(6):e1039–e1044. doi: 10.1542/peds.2008-2828.
    1. Werner SL, Smith CE, Goldstein JR, Jones RA, Cydulka RK. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. 2007;5(1):75–80. doi: 10.1016/j.annemergmed.2006.07.004.
    1. Galicinao J, Bush AJ, Godambe SA. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: a feasibility study. Pediatrics. 2007;5(6):1297–1303. doi: 10.1542/peds.2006-2959.
    1. Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology. 2012;5(3):185–189. doi: 10.1159/000338585.
    1. Hsieh KS, Lee CL, Lin CC, Huang TC, Weng KP, Lu WH. Secondary confirmation of endotracheal tube position by ultrasound image. Crit Care Med. 2004;5(9 Suppl):S374–S377.
    1. Chun R, Kirkpatrick AW, Sirois M, Sargasyn AE, Melton S, Hamilton DR, Dulchavsky S. Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disaster Med. 2004;5(4):366–369.
    1. Merritt CR. Ultrasound safety: what are the issues? Radiology. 1989;5(2):304–306.
    1. World Health Organization. Training in diagnostic ultrasound: essentials, principles and standards. Report of a WHO study group: technical report series no. 875. Geneva: WHO; 1998.
    1. Bricker L, Garcia J, Henderson J, Mugford M, Neilson J, Roberts T, Martin MA. Ultrasound screening in pregnancy: a systematic review of the clinical effectiveness, cost-effectiveness and women’s views. Health Technol Assess. 2000;5(16):i–vi. 1–193.
    1. Romolo Joseph Gaspari JCF, Sierzenski PR. Emergency ultrasound: principles and practice. Maryland Heights Geneva: Mosby; 2005.
    1. Kwok TC, Johnson S, Reed MJ. Impact of the introduction of emergency ultrasound to one large UK emergency department: the REBUS study. Emerg Med J. 2013;5(2):112–116. doi: 10.1136/emermed-2011-201028.
    1. Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med. 2012;5(2):338–341. doi: 10.1016/j.ajem.2010.12.016.
    1. Kevin J, Knoop LBS, Storrow AB. Atlas of emergency medicine. New York: McGraw-Hill Professional; 2002.
    1. Malhotra RK, Indrayan A. A simple nomogram for sample size for estimating sensitivity and specificity of medical tests. Indian J Ophthalmol. 2010;5(6):519–522. doi: 10.4103/0301-4738.71699.
    1. Altman DG. Statistics in medical journals: developments in the 1980s. Stat Med. 1991;5(12):1897–1913. doi: 10.1002/sim.4780101206.
    1. Docherty M, Smith R. The case for structuring the discussion of scientific papers. BMJ. 1999;5(7193):1224–1225. doi: 10.1136/bmj.318.7193.1224.
    1. Takeda T, Tanigawa K, Tanaka H, Hayashi Y, Goto E, Tanaka K. The assessment of three methods to verify tracheal tube placement in the emergency setting. Resuscitation. 2003;5(2):153–157. doi: 10.1016/S0300-9572(02)00345-3.
    1. MacLeod BA, Heller MB, Gerard J, Yealy DM, Menegazzi JJ. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med. 1991;5(3):267–270. doi: 10.1016/S0196-0644(05)80937-0.
    1. Bhende MS, Thompson AE, Cook DR, Saville AL. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann Emerg Med. 1992;5(2):142–145.
    1. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of sonography for airway assessment: an observational study. J Ultrasound Med. 2010;5(1):79–85.
    1. Carp H, Bundy A. A preliminary study of the ultrasound examination of the vocal cords and larynx. Anesth Analg. 1992;5(4):639–640. doi: 10.1213/00000539-199210000-00041.
    1. Drescher MJ, Conard FU, Schamban NE. Identification and description of esophageal intubation using ultrasound. Acad Emerg Med. 2000;5(6):722–725. doi: 10.1111/j.1553-2712.2000.tb02055.x.
    1. Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign. Acad Emerg Med. 2006;5(3):239–244. doi: 10.1111/j.1553-2712.2006.tb01685.x.
    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;5(7):490–493. doi: 10.1136/emj.2004.015818.
    1. Andersen KH, Schultz-Lebahn T. Oesophageal intubation can be undetected by auscultation of the chest. Acta Anaesthesiol Scand. 1994;5(6):580–582. doi: 10.1111/j.1399-6576.1994.tb03955.x.
    1. Maleck WH, Koetter KP. Verification of tracheal tube placement. Ann Emerg Med. 1995;5(4):527–528.
    1. Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation. J Emerg Med. 2001;5(3):223–229. doi: 10.1016/S0736-4679(00)00318-8.
    1. Clyburn P, Rosen M. Accidental oesophageal intubation. Br J Anaesth. 1994;5(1):55–63. doi: 10.1093/bja/73.1.55.
    1. Oulego-Erroz I, Alonso-Quintela P, Rodriguez-Blanco S, Mata-Zubillaga D, Fernandez-Miaja M. Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant. Resuscitation. 2012;5(6):e143–e144. doi: 10.1016/j.resuscitation.2012.02.014.
    1. Pfeiffer P, Bache S, Isbye DL, Rudolph SS, Rovsing L, Borglum J. Verification of endotracheal intubation in obese patients - temporal comparison of ultrasound vs. auscultation and capnography. Acta Anaesthesiol Scand. 2012;5(5):571–576. doi: 10.1111/j.1399-6576.2011.02630.x.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner