Brandon Chaffay, MD
George Washington University Hospital
Washington, District of Columbia
Disclosure information not submitted.
Philip Dela Cruz, n/a
Resident Physician
UHS SoCal MEC Internal Medicine Residency, United States
Disclosure information not submitted.
David Yamane, BS, MD
Assistant Professor of Emergency Medicine, Anesthesiology, and Critical Care Medicine
George Washington University Hospital, United States
Disclosure information not submitted.
Mark Munoz, MD
Critical Care Fellow
Georgetown University Hospital, United States
Disclosure information not submitted.
Title: Endotracheal Tube Surveillance: Can Point of Care Ultrasound Replace Chest Radiographs?
Introduction: There are many potential complications associated with endotracheal tube (ETTs) malpositioning in critical care settings, such as bronchial migration or vocal cord herniation. These events can prolong patient recovery and lengthen ICU stays. The goal of this study is to demonstrate that point of care ultrasound (POCUS) is noninferior to chest x-ray (CXR) in identifying proper ETT depth.
Methods: We conducted an observational cohort study of intubated patients across 4 multidisciplinary ICUs at an urban academic hospital who underwent daily POCUS assessment of ETT positioning by novice sonographers (medical students). ICU/ED physicians led 4 hour-long informal trainings to teach medical students POCUS technique. Subjects were excluded if they were COVID positive, in c-spine precautions, had recent neck surgery or planned to be extubated within 24 hours. Patient ETT position was measured using POCUS assessment (balloon cuff border ending between 3-7 tracheal rings) and compared to daily radiographic CXR landmarks (5 cm +/- 2 cm above carina). Recommendations based on sonographic and radiographic landmarks were compared to assess sensitivity and specificity of POCUS to evaluate need for ETT repositioning. Statistical significance was assessed using the Clopper-Pearson binomial confidence interval.
Results: 20 patients were enrolled for a total of 62 ventilator-days. The cohort was majority female (55%), Black/African American (75%) and mean age 55 +/- 18 years. In 58 instances (93.5%), both sonographic and radiographic landmarks agreed on maintenance of ETT position. In 1 instance (1.6%), sonographers recommended ETT repositioning while radiographic landmarks did not. In 3 instances (4.8%), ETTs appeared in place by sonographic but not radiographic landmarks. The data yields a specificity of 98.31% CI [90.91,99.96] for proper ETT placement with a negative likelihood ratio of 1.02 CI [.98, 1.05] and NPV of 95.08% CI [94.92,95.24].
Conclusion: The high specificity and NPV values suggest that if ETT position appears within normal limits on POCUS (tip of ETT between 3-7 tracheal rings), ETT position is likely adequately positioned even when performed by novices. Further studies should investigate the use of POCUS as a monitoring alternative and as a reliable tool post-intubation to confirm ETT depth.