Clinical paperTracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation☆,☆☆
Introduction
Establishing a secure airway in critically ill patients is a primary step during resuscitation. According to the 2010 Advanced Cardiac Life Support (ACLS) guidelines, adequate support of ventilation during resuscitation is essential.1 Proper endotracheal tube intubation provides definitive airway control. Nevertheless, unrecognized endotracheal tube misplacement can lead to significant mortality and morbidity, and is more likely to occur during emergent situations. The reported incidence of esophageal intubation was about 6–16% during emergency intubation.2, 3 Thus, early detection of accidental esophageal intubation is a primary focus during resuscitation.
Many traditional methods can be employed to confirm endotracheal tube placement, including direct visualization of the vocal cords, observation of chest movement, and chest and gastric auscultation. Each of these methods has limitations, and is not entirely reliable in the emergency setting.4, 5 Studies found that quantitative capnography is the most sensitive tool for confirming tracheal intubation.4, 5, 6 According to the 2010 ACLS guidelines, quantitative waveform capnography is recommended as the most reliable method for confirming endotracheal tube placement.1 However, capnography is still not widely available in some emergency departments (EDs) and intensive care units (ICUs).7 A confirmation technique that is widely available and accurate would be desirable when waveform capnography is not available.
Ultrasound is a common examination tool in many EDs and ICUs. To assist with airway management in critically ill patients, ultrasound is very useful due to its low-cost and portable capability.8 Several studies have provided promising results of the use of ultrasound for the confirmation of endotracheal tube placement in cadaveric models and in patients in well-controlled environments.9, 10, 11, 12, 13, 14, 15, 16 Two recent studies showed up to 100% of sensitivity and specificity of tracheal ultrasound for endotracheal tube placement confirmation in live humans under a well-controlled operating room setting.14, 15 To date, few studies have been conducted in emergency settings, so that validation of this potentially useful technique in emergent situations is urgently needed.
We proposed a tracheal rapid ultrasound examination (T.R.U.E.) method for rapid and accurate confirmation of the endotracheal tube position during emergency intubation. This study aimed to assess the diagnostic accuracy and timeliness of the T.R.U.E. in confirming endotracheal tube position during emergency intubation.
Section snippets
Study design and setting
This was a prospective, single-center, observational study, conducted between March 2010 and December 2010. The study protocol was approved by the Institutional Review Board of the National Taiwan University Hospital with a waiver of informed consents. All subjects were recruited from the ED of National Taiwan University Hospital, which is a 2000-bed, tertiary teaching hospital. The emergency department cares for more than 100,000 patients each year.
Selection of participants
Patients were prospectively enrolled during
Results
Of the 173 eligible patients, a total of 112 (64.7%) patients, with ages of 24–94 years old, were included in the final analyses, between March 2010 and December 2010 (Fig. 2). Their demographics and clinical characteristics are listed in Table 1. The mean age was 67.4 ± 17.6 years. The mean BMI was 23.1 ± 4.8 kg/m2. Among 112 patients, 18 out-of-hospital and 11 in-hospital cardiac arrest patients were intubated. The remaining 83 patients were intubated for other medical emergencies. The mean
Discussion
This prospective study aimed to assess accuracy and timeliness of tracheal ultrasound for determining endotracheal tube placement during emergency intubation. In this study, tracheal ultrasound achieved high sensitivity and specificity for confirming endotracheal tube placement. Therefore, ultrasound can serve as a good diagnostic tool for confirming tracheal intubation during resuscitation.
According to the 2010 ACLS guidelines, endotracheal tube position should be verified by both clinical
Conclusions
This prospective study indicated that the application of the T.R.U.E. to examine endotracheal tube placement during emergency intubation is feasible, and can be rapidly performed. Thus, tracheal ultrasound can be considered as the secondary confirmation method for endotracheal tube placement during resuscitation.
Conflicts of interest statement
None.
Acknowledgement
We would like to thank Fu-Chang Hu, MS, ScD, for suggestions for statistical analysis and assistance with statistical computing.
References (28)
- et al.
The assessment of three methods to verify tracheal tube placement in the emergency setting
Resuscitation
(2003) - et al.
The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model
J Emerg Med
(2007) - et al.
Transtracheal 2-d ultrasound for identification of esophageal intubation
J Emerg Med
(2007) - et al.
Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement
Ann Emerg Med
(2007) - et al.
Bias, prevalence and kappa
J Clin Epidemiol
(1993) - et al.
C.A.U.S.E.: Cardiac arrest ultra-sound exam—a better approach to managing patients in primary non-arrhythmogenic cardiac arrest
Resuscitation
(2008) 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 8.1: Adjuncts for airway control and ventilation
Circulation
(2010)- et al.
Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations
Anesthesiology
(1995) 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)Comparison of three different methods to confirm tracheal tube placement in emergency intubation
Intensive Care Med
(2002)
The assessment of four different methods to verify tracheal tube placement in the critical care setting
Anesth Analg
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
Role of ultrasound in the airway management of critically ill patients
Crit Care Med
Ultrasound confirmation of endotracheal tube placement
J Clin Ultrasound
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Trial Registration: ClinicalTrials.gov number: NCT01148732.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.05.016.