Date: March 12th, 2019

Reference: Gottlieb, Holladay and Peksa. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med 2018.

Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He hosts a great #FOAMed blog and podcast called TOTAL EM. Chip is also the CEO of a new educational company called Practical POCUS.

Case: A 48-year-old male is in cardiac arrest and is not being successfully oxygenated by bag valve mask or with a supraglottic airway (SGEM#246).  While preparing to intubate the patient, you consider ways of quickly confirming endotracheal tube placement.  You have a colleague in the room who is proficient at ultrasound and asks if there is a role for bedside ultrasound in this situation.

Background: We have talked about ultrasound a number of times on the SGEM:

* SGEM#245: Flash-errrs (POCUS for Retinal Detachments)

* SGEM#177: POCUS – A New Sensation for Diagnosing Pediatric Fractures

* SGEM#153: Simulation for Ultrasound Education

* SGEM#124: Ultrasound for Skull Fractures – Little Bones

* SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound)

The SGEM has also discussed endotracheal intubation a number of times:

* SGEM#247: Supraglottic Airways Gonna Save you for an OHCA?

* SGEM#197: Die Trying – Intubation of In-Hospital Cardiac Arrests

* SGEM#186: Apneic and the O, O, O2 for Rapid Sequence Intubations

* SGEM#75: Video Killed Direct Laryngoscopy?

Endotracheal intubation can be challenging and if incorrectly performed can lead to death.  Rapid confirmation of endotracheal tube placement is vital and ACEP has a policy statement on this issue. The various methods to confirm tube placement include:

* Physical exam (auscultation of chest and epigastrium, chest wall movement, and condensation/fogging in the tube)

* Direct visualization or videolaryngoscope of the tube going through the cords

* Pulse oximetry

* Chest x-ray

* Esophageal detector devices

* End-tidal carbon dioxide (CO2) detection (continuous wave form capnography, colorimetric and non-wave form capnography)

There is evidence indicating that commonly used endpoints for rapid confirmation can be inaccurate.  Quantitative waveform capnography, thought to be one of the best methods, correctly confirms tube placement only two-thirds of the time in cardiac arrest (Takeda et al, Tanigawa et al and