PEM POCUS Series: Confirmation of Endotracheal Tube Placement
Read this tutorial on the use of point of care ultrasonography (POCUS) for confirmation of endotracheal tube (ETT) placement in pediatric patients. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Module Goals
- List indications for performing airway/lung POCUS to confirm ETT placement
- Describe the technique of performing airway and focused lung POCUS
- Distinguish between normal and abnormal airway and lung POCUS findings
- Distinguish between tracheal, endobronchial, and esophageal placement of ETT
- List the limitations of airway and lung POCUS
Case Introduction: The Postictal Toddler
Joey is a 2-year-old male with a history of epilepsy who presents to a community hospital emergency department with generalized tonic-clonic seizures of more than 45 minutes duration. After receiving 2 doses of IV midazolam, he stopped seizing. He has very shallow breathing and oxygen saturations as low as 90 percent on 2 liters of supplemental oxygen via nasal cannula. The pediatric transport team arrives to transport him to another hospital for admission and note that he is somnolent with poor respiratory effort. His current vital signs:
Vital Sign | Finding |
---|---|
Temperature | 37.0 C |
Heart Rate | 115 bpm |
Blood Pressure | 85/65 |
Respiratory Rate | 12 |
Oxygen Saturation (room air) | 92% on 2 L via nasal cannula |
An end tidal carbon dioxide (ETCO2) monitor shows a ETCO2 level in the high 70s mmHg. The decision is made to intubate the patient given disordered breathing, hypercapnia, and hypoxia following medical management of seizures. The transport team would like to use POCUS to evaluate ETT placement at the outside hospital and during transport.
For simplicity, this module will focus on 3 modes of using POCUS for ETT confirmation. Collectively, these techniques can help improve evaluation.
Case Resolution
After administration of fentanyl, midazolam, and rocuronium, the patient was intubated with a 4.0 cuffed ETT by direct laryngoscopy with a Macintosh blade.
POCUS was used to confirm ETT placement by the transport team in the community hospital ED. Specifically, the provider directly visualized the in the anterior neck (with a single air-mucosa interface), the presence of bilateral lung sliding, and movement of the diaphragm towards the abdomen with PPV. End tidal CO2 further confirmed accurate placement. Once loaded into the ambulance, the ETT was again confirmed to be in the trachea.
Video 11: POCUS showing bilateral lung sliding
Video 12. POCUS showing diaphragmatic movement down to the abdomen with breathing.
Learn More…
References
- Tsung JW, Fenster D, Kessler DO, Novik J. Dynamic anatomic relationship of the esophagus and trachea on sonography: implications for endotracheal tube confirmation in children. Journal of Ultrasound in Medicine. 2012 Sep;31(9):1365-70. PMID 22922616
- Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid ultrasound saline test (TRUST) for confirming correct endotracheal tube depth in children. Resuscitation. 2015 Apr 1;89:8-12. PMID 25238740
- Lin MJ, Gurley K, Hoffmann B. Bedside Ultrasound for Tracheal Tube Verification in Pediatric Emergency Department and ICU Patients: A Systematic Review. Pediatr Crit Care Med. 2016;17(10):e469-e476. PMID 27487913
- Sahu AK, Bhoi S, Aggarwal P, et al. Endotracheal tube placement confirmation by ultrasonography: A systematic review and meta-analysis of more than 2500 patients. J Emerg Med. 2020 Aug 1;59(2):254-64. PMID 32553512
- Lonchena T, So S, Ibinson J, Roolf P, Orebaugh SL. Optimization of ultrasound transducer positioning for endotracheal tube placement confirmation in cadaveric model. J Ultrasound Med. 2017 Feb;36(2):279-84. PMID 28072483
- Galicinao J, Bush AJ, Godambe SA. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: A feasibility study. Pediatrics 2007; 120:1297–1303. PMID 18055679
- Alonso Quintela P, Oulego Erroz I, Mora Matilla M, et al: [Usefulness of bedside ultrasound compared to capnography and radiograph for tracheal intubation]. An Pediatr (Barc) 2014; 81:283–288. PMID 24560730
- 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 Sep;32(9 Suppl):S374-7. PMID 15508663
- Kerrey BT, Ceis GL, Quinn AM. A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal. Pediatrics. 2009;123:1039-43. PMID 19414520
- Jaeel P, Sheth M, Nguyen J. Ultrasonography for endotracheal tube position in infants and children. Eur J Pediatr. 2017 Mar;176(3):293-300. PMID 28091777
- Uya A, Gautam NK, Rafique MB, et al. Point-of-Care Ultrasound in Sternal Notch Confirms Depth of Endotracheal Tube in Children. Pediatr Crit Care Med. 2020;21(7):e393-e398. PMID 32168296
Additional Reading
- Adhikari S, Blaivas M. The Ultimate Guide to Point-of-Care Ultrasound-Guided Procedures. 1st Ed. Springer Nature; 2020.
- Blaivas M, Tsung JW. Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation. J Ultrasound Med. 2008;27(5):785-789. doi:10.7863/jum.2008.27.5.785. PMID 18424655
- Chou EH, Dickman E, Tsou PY, et al. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation. 2015;90:97-103. doi:10.1016/j.resuscitation.2015.02.013. PMID 25711517
- Hoffmann B, Gullett JP, Hill HF, et al. Bedside ultrasound of the neck confirms endotracheal tube position in emergency intubations. Ultraschall Med. 2014;35(5):451-458. doi:10.1055/s-0034-1366014. PMID 25014479
- Lahham S, Baydoun J, Bailey J, et al. A Prospective Evaluation of Transverse Tracheal Sonography During Emergent Intubation by Emergency Medicine Resident Physicians. J Ultrasound Med. 2017;36(10):2079-2085. doi:10.1002/jum.14231. PMID 28503749
- Marciniak B, Fayoux P, Hébrard A, et al. Airway management in children: ultrasonography assessment of tracheal intubation in real time?. Anesth Analg. 2009;108(2):461-465. doi:10.1213/ane.0b013e31819240f5. PMID 19151273
- 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. J Ultrasound Med. 2019;38(11):2945-2954. doi:10.1002/jum.15000. PMID 30993739
- Prada G, Vieillard-Baron A, Martin AK, et al. Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth. 2021;35(1):310-322. doi:10.1053/j.jvca.2019.11.051. PMID 31883769
- 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(3):353-358. doi:10.4103/joacp.JOACP_317_18. PMID 31543584
- Sim SS, Lien WC, Chou HC, et al. Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency intubation. Resuscitation. 2012;83(3):307-312. doi:10.1016/j.resuscitation.2011.11.010. PMID 22138058
- 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;29(1):79-85. doi:10.7863/jum.2010.29.1.79. PMID 20040778
- Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign. Acad Emerg Med. 2006;13(3):239-244. doi:10.1197/j.aem.2005.08.014. PMID 16495415