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: ARE ULTRASOUNDS AS SAFE AS CHEST X-RAYS AT ASSESSING COMPLICATIONS OF ENDOTRACHAEL INTUBATIONS?
Introduction:
Endotracheal tube (ETT) complications are common in intensive care unit (ICU) settings due to ETT malpositioning and migration. Point-of-care ultrasound (POCUS) has shown promise in predicting accurate ETT position but the safety profile compared to chest x-rays (CXR) remains unknown. We assessed whether a POCUS-guided repositioning protocol was non-inferior to CXRs for adverse clinical outcomes.
Methods:
Intubated patients enrolled from 4 multi-disciplinary ICUs over a 1-month period were randomized into two arms: CXR-guided or POCUS-guided daily monitoring of ETT position. In the POCUS-arm, novice sonographers assessed ETT positioning daily (normal range: superior balloon border between the 3rd-7th tracheal rings) and recommended repositioning maneuvers accordingly. The protocol allowed clinicians to use CXR landmarks if they did not agree with POCUS recommendations. The CXR-arm used radiographic landmarks (normal range: ETT tip 5±2cm from carina) without sonography. Exclusion criteria included COVID-19 status, C-spine precautions, prone positioning, anterior neck wounds, or planned extubation within 24 hours. Investigators used Fisher’s exact test (α-error 5%) to compare rates of ETT bronchial or vocal cord migration, balloon rupture, unplanned extubation, repositioning maneuvers, and ventilator associated pneumonia (VAP).
Results:
22 patients met inclusion criteria with 11 patients in the POCUS-arm (35 ventilator-days) and 11 patients in the CXR-arm (36 ventilator-days). There was no significant difference in adverse events between the CXR- and POCUS-arms (7.50% v 3.13%; p=0.41). There were 6 instances of patients crossing-over from the POCUS-arm to the CXR-arm but a secondary intention-to-treat analysis showed no impact on significance (7.50% v 3.13%; p=0.41). 3 VAP episodes occurred in the CXR-arm and 1 vocal cord herniation occurred in the POCUS-arm. Repositioning was more common in the CXR-arm than the POCUS-arm (23.5% v 0.00%; p=0.02).
Conclusions:
The use of POCUS compared to daily CXRs to monitor ETT positioning appears similar in terms of the adverse clinical outcomes. Further investigation is needed to assess if this non-inferiority remains with higher sample sizes.