PEDIATRICS Vol. 122 No. 1 July 2008, pp. 214-215 (doi:10.1542/peds.2008-1128)
LETTER TO THE EDITOR |
Bedside Ultrasonography and Endotracheal Tube Placement: A Long Way to Go: In Reply
Jeanette Galicinao, MDDonald T. Ellis, II, MD
Sandip A. Godambe, MD, PhD
Division of Pediatric Emergency Medicine
Department of Pediatrics
University of Tennessee Health Sciences Center
Memphis, TN 38103
We thank Sundaram et al for their interest in our published study1; they raise several important points that deserve discussion. With regards to their first point, direct laryngoscopy (DL) is unequivocally the gold standard for confirming endotracheal tube (ETT) placement. DL is not always possible, and ETTs can slip out of place before being secured or move during transport.2 Colorimetric end-tidal carbon dioxide detection (CECD) remains the standard for secondary confirmation of ETT position in the trachea.3 We propose the use of both CECD and bedside ultrasonography (BUS), along with DL and clinical examination, to confirm ETT placement.
Regarding their second question, as to whether the ETT may have actually been esophageal in the 2 patients with severe bronchospasm, both of these patients were reintubated twice under DL in exactly the same manner. The ETT was seen passing through the vocal cords in each instance, and it was not until external pressure was applied to the chest that the CECD changed color. After every placement, BUS showed the position of the tube as endotracheal. BUS did not impair resuscitative efforts in any way.
The use of the cricothyroid membrane (CTM) permitted a consistent location as to the placement of the ultrasound transducer, and its size did not affect our ability to acquire an image. Given the close proximity of the trachea to the CTM plus the transmissibility of ultrasonographic waves through the surrounding tissue, this view can be obtained without difficulty in newborns. In fact, Werner et al4 demonstrated that a BUS view just below the CTM and above the suprasternal notch could also be used to differentiate between esophageal and tracheal intubation.
Multiple physician scientists (refs 1 and 4–11; D.T.E., A.J. Bush, PhD, S.A.G., unpublished data) have suggested important roles for BUS-determined ETT placement. BUS may have a role in extreme settings with noise and lighting limitations, such as remote prehospital settings, busy trauma bays, or during aeromedical transport, in which DL, auscultation, or CECD-based confirmation of ETT placement may be equivocal. Second, during situations of poor pulmonary blood flow such as cardiac arrest, CECD will be unreliable, and BUS may play a role for secondary confirmation of ETT placement. In addition, BUS may have a role in detecting ETT placement in settings of acute bronchospasm, which may not permit sufficient air movement to allow for proper auscultation or may render CECD inconclusive. BUS also allows for the supervision of physicians in training as they perform endotracheal intubation without hindering the process. Finally, mastery of neck and chest sonography may eventually aid in the early recognition of pneumothoraxes, pulmonary contusions, or distorted neck anatomy in both traumatic and nontraumatic settings before the process of ETT placement is undertaken.
In conclusion, we again thank Sundaram et al for their interest in our article. Although they voice several interesting points for discussion, none disprove the growing body of evidence that BUS has a promising future, as demonstrated not only by our study but also by the previous and current research efforts of other groups.
REFERENCES
- Galicinao J, Bush AJ, Godambe SA. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: a feasibility study.
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[Abstract/Free Full Text] - American College of Emergency Physicians. Verification of endotracheal tube placement (policy 400307). Available at: www.acep.org/practres.aspx?id=29846. Accessed May 3, 2008
- Hazinski MF, Zaritsky AL, Nadkarni VM, Hickey RW, Schexnayder SM, Berg RA, eds. Airway, ventilation, and management of respiratory distress and failure. In: Pediatric Advanced Life Support: Provider Manual. Dallas, TX: American Heart Association; 2002:104–105
- 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; 49 (1):75 –80[CrossRef][Web of Science][Medline]
- Drescher MJ, Conard FU, Schamban NE. Identification and description of esophageal intubation using ultrasound. Acad Emerg Med.2000; 7 (6):722 –725[Web of Science][Medline]
- Raphael DT, Conard FU III. Ultrasound confirmation of endotracheal tube placement. J Clin Ultrasound.1987; 15 (7):459 –462[Web of Science][Medline]
- Slovis TL, Poland RL. Endotracheal tubes in neonates: sonographic positioning.
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[Abstract/Free Full Text] - Lingle PA. Sonographic verification of endotracheal tube position in neonates: a modified technique. J Clin Ultrasound.1988; 16 (8):605 –609[Web of Science][Medline]
- 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; 32 (9 suppl):S374 –S377[CrossRef][Medline]
- Chun R, Kirkpatrick AW, Sirois M, et al. Where's the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disaster Med.2004; 19 (4):366 –369[Medline]
- 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[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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