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Ultrasound confirmation of ETT placement

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Ultrasound confirmation of ETT placement

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Ultrasound confirmation of ETT placement

  1. 1. Ultrasound confirmation of endotracheal tube placement Dr James Wheeler BSc MBBS FACEM DDU Emergency Physician, SCGH +
  2. 2. Will this replace traditional methods of ETT confirmation? • Specifically, does this replace capnography and auscultation • NO! • BUT: • No single confirmatory method is entirely reliable esp. in emergency situations, and • In certain circumstances US confirmation can be a very helpful adjunct
  3. 3. Why would you do it? • Transtracheal ultrasound is a relatively SIMPLE technique • FAST (~8 sec vs 18 sec for capnography1) • May be more reliable than capnography changes in certain patient groups? • SENSITIVE and SPECIFIC 2,3,4 • The pooled sensitivity and specificity for the detection of proper ETT placement with US were: • Sensitivity: 98% (95% C.I. 97-99%); Specificity: 98% (95% C.I. 95-99%); PPV: 99.5%, NPV: 93.8% • Does not require ventilations to assess tube placement • May prevent gastric insufflation and delay in diagnosis of misplacement
  4. 4. When would you use it? • When ETCO2 unreliable (or not available?) • Cardiac arrest / massive PE • Emergency blind intubation / predicted difficult intubation • Patient arrives intubated and requires rapid confirmation of ETT placement • Any patient not responding as expected after ETT placement prior to attempting re-intubation
  5. 5. How do you do it? Direct (Transtracheal) • Looking for evidence of direct endotracheal intubation OR oesophageal intubation (a “second trachea”) • During intubation OR Post-intubation Indirect (Transthoracic) • Looking at the pleural space for evidence of lung ventilation (pleural movement) • Post-intubation
  6. 6. Direct: Technique Probe: • high frequency (6-12MHz) linear probe (but can use lower freq micro convex or curvilinear in obese) Preset: • Superficial, depth sufficient to see posterior to trachea, focal zone at trachea Probe placement: • In transverse plane just above the suprasternal notch • i.e. beneath cricoid
  7. 7. Direct: Technique Endotracheal intubation: • One air-mucosal interface • Hyperechoic reverberation artefacts inside trachea OR Oesophageal intubation: • Dynamic opening of the oesophagus by the ETT seen on US performed during laryngoscopy • Two air-mucosal interfaces (“two tracheas” , “double track sign”) • Hyperechoic reverberation artifacts inside oesophagus May also interrogate cuff position by infiltrating saline
  8. 8. Direct: US Anatomy
  9. 9. Direct: Tracheal Intubation
  10. 10. Direct - Oesophageal Intubation
  11. 11. Indirect • Looking at the pleural space for evidence of lung ventilation (pleural movement) • Differential pleural movement may indicate RMS intubation • Requires ventilation
  12. 12. Indirect US Anatomy
  13. 13. Indirect: Ventilating Lung
  14. 14. Indirect: Non-Ventilating Lung
  15. 15. Indirect: Pneumothorax
  16. 16. Indirect: Pneumothorax (Lung Point)
  17. 17. Pitfalls? • Requires access to US machine • No single confirmatory method is entirely reliable (esp. in emergency situations) • Operator dependent • Surgical emphysema may obscure view • Can’t identify supraglottic airway • Pneumothorax (for indirect)
  18. 18. References 1. Reliability of Ultrasonography in Confirming Endotracheal Tube Placement in an Emergency Setting. Vimal Koshy, Thomas et al. Indian J Crit Care Med. 2017 May; 21(5): 257–261. 2. Transtracheal ultrasound for verification of endotracheal tube placement: a systematic review and meta-analysis. Das SK1, Choupoo NS, Haldar R, Lahkar A. Can J Anaesth. 2015 Apr;62(4):413-23 3. Ultrasonography for confirmation of endotracheal tube placement: A systematic review and meta-analysis. Eric H.Chou et al. Resuscitation, Volume 90, May 2015, 97-103 4. Can Transtracheal Ultrasonography Be Used to Verify Endotracheal Tube Placement? Gottlieb M, Bailitz J .Ann Emerg Med. 2015 Oct; 66(4): 394-5

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