Various methods exist to confirm endotracheal tube (ETT) position. Clinical verification, followed by chest radiography, is typically performed. However, translaryngeal ultrasound (TLUS) is sensitive and specific for identifying intratracheal position. Additionally, transpleural ultrasound (TPUS) identifies mainstem intubation by showing unilateral absence of pleural sliding. TLUS, therefore, can identify proximal ETT malposition, and TPUS can identify distal malposition. To date there has been no study that combines the use of TLUS and TPUS and compares them to chest radiography.
IRB approval was obtained. Patients intubated in the adult MICU were considered for inclusion. Exclusion criteria were pneumothorax, prior pleurodesis, and presence of interfering subcutaneous air. Following intubation, TLUS was performed with a 6–13 mHz linear array transducer, imaging the trachea longitudinally and transversely. Once intra-tracheal position was confirmed, the ETT tip was localized. If the tip was visible above the sternal notch but below the vocal cords, the position was deemed satisfactory, and TPUS was not performed. If the tip was not visible, evidenced by the tube coursing under the sternal notch, TPUS was performed to evaluate for distal malposition (see figure 1). In patients with unilateral abscence of pleural sliding, effusion or pneumothorax were evaluated for sonographically and, if negative, the diagnosis of distal ETT malposition was made. A CXR was then performed, taking care not to change the position of the ETT, and the results were compared to ultrasound (US).
14 patients have been enrolled. All were intubated by direct laryngoscopy in the ICU, and were confirmed to have intra-tracheal intubation by TLUS. The ETT tip was visualized by TLUS in 6 patients. In the remaining 8 patients, TPUS suggested right mainstem intubation in 2 as evidenced by an absence of pleural sliding on the right. There was 100% correlation between US and chest radiography.
A combination of translaryngeal and transpleural ultrasound indentifies clinically relevant ETT malposition as well as chest radiography.
Post intubation US could be first line to detect ETT malposition.
Christian Butcher, No Financial Disclosure Information; No Product/Research Disclosure Information