[New post] PEM POCUS Series: Confirmation of Endotracheal Tube Placement

Nichole McCollum, MD posted: "" PEM POCUS Series: Confirmation of Endotracheal Tube Placement Nichole McCollum, MD May 2 Take the ALiEMU PEM POCUS: Pediatric ETT Confirmation Quiz 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: 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... PEM POCUS Series Ultrasound for the Win Series 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. 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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 Comment Unsubscribe to no longer receive posts from ALiEM. Change your email settings at manage subscriptions. Trouble clicking? Copy and paste this URL into your browser: https://www.aliem.com Powered by Jetpack