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      A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation

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          Abstract

          Background

          In emergency settings, verification of endotracheal tube (ETT) location is important for critically ill patients. Ignorance of oesophageal intubation can be disastrous. Many methods are used for verification of the endotracheal tube location; none are ideal. Quantitative waveform capnography is considered the standard of care for this purpose but is not always available and is expensive. Therefore, this feasibility study is conducted to compare a cheaper alternative, bedside upper airway ultrasonography to waveform capnography, for verification of endotracheal tube location after intubation.

          Methods

          This was a prospective, single-centre, observational study, conducted at the HRPB, Ipoh. It included patients who were intubated in the emergency department from 28 March 2012 to 17 August 2012. A waiver of consent had been obtained from the Medical Research Ethics Committee. Bedside upper airway ultrasonography was performed after intubation and compared to waveform capnography. Specificity, sensitivity, positive and negative predictive value and likelihood ratio are calculated.

          Results

          A sample of 107 patients were analysed, and 6 (5.6%) had oesophageal intubations. The overall accuracy of bedside upper airway ultrasonography was 98.1% (95% confidence interval (CI) 93.0% to 100.0%). The kappa value ( Κ) was 0.85, indicating a very good agreement between the bedside upper airway ultrasonography and waveform capnography. Thus, bedside upper airway ultrasonography is in concordance with waveform capnography. The sensitivity, specificity, positive predictive value and negative predictive value of bedside upper airway ultrasonography were 98.0% (95% CI 93.0% to 99.8%), 100% (95% CI 54.1% to 100.0%), 100% (95% CI 96.3% to 100.0%) and 75.0% (95% CI 34.9% to 96.8%). The likelihood ratio of a positive test is infinite and the likelihood ratio of a negative test is 0.0198 (95% CI 0.005 to 0.0781). The mean confirmation time by ultrasound is 16.4 s. No adverse effects were recorded.

          Conclusions

          Our study shows that ultrasonography can replace waveform capnography in confirming ETT placement in centres without capnography. This can reduce incidence of unrecognised oesophageal intubation and prevent morbidity and mortality.

          Trial registration

          National Medical Research Register NMRR11100810230.

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          Most cited references42

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          Comparison of three different methods to confirm tracheal tube placement in emergency intubation.

          Štefek Grmec (2002)
          Verification of endotracheal tube placement is of vital importance, since unrecognized esophageal intubation can be rapidly fatal (death, brain damage). The aim of our study was to compare three different methods for immediate confirmation of tube placement: auscultation, capnometry and capnography in emergency conditions in the prehospital setting. Prospective study in the prehospital setting. All adult patients (>18 years) were intubated by an emergency physician in the field. Tube position was initially evaluated by auscultation. Then, capnometry was performed with infrared capnometry and capnography with infrared capnography. The examiners looked for the characteristic CO(2) waveform and value of end-tidal carbon dioxide (EtCO(2)) in millimeters of mercury. Determination of final tube placement was performed by a second direct visualization with laryngoscope. Data are mean +/- SD and percentages. Over a 4year period, 345 patients requiring emergency intubation were included. Indications for intubation included cardiac arrest ( n=246; 71%) and non-arrest conditions ( n=99; 29%). In nine (2.7%) patients, esophageal tube placement occurred. The esophageal intubations were followed by successful endotracheal intubations without complications. The capnometry (sensitivity and specificity 100%) and capnography (sensitivity and specificity 100%) were better than auscultation (sensitivity 94% and specificity 83%) in confirming endotracheal tube placement in non-arrest patients ( p<0.05). Capnometry was highly specific (100%) but not sensitive (88%) for correct endotracheal intubation in patients with cardiopulmonary arrest (capnometry versus auscultation and capnometry versus capnography, p<0.05). Capnography is the most reliable method to confirm endotracheal tube placement in emergency conditions in the prehospital setting.
          Article 0 comments Cited 70 times – based on 0 reviews     Review now
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            A simple nomogram for sample size for estimating sensitivity and specificity of medical tests

            Rajeev Malhotra, A Indrayan (2010)
            Sensitivity and specificity measure inherent validity of a diagnostic test against a gold standard. Researchers develop new diagnostic methods to reduce the cost, risk, invasiveness, and time. Adequate sample size is a must to precisely estimate the validity of a diagnostic test. In practice, researchers generally decide about the sample size arbitrarily either at their convenience, or from the previous literature. We have devised a simple nomogram that yields statistically valid sample size for anticipated sensitivity or anticipated specificity. MS Excel version 2007 was used to derive the values required to plot the nomogram using varying absolute precision, known prevalence of disease, and 95% confidence level using the formula already available in the literature. The nomogram plot was obtained by suitably arranging the lines and distances to conform to this formula. This nomogram could be easily used to determine the sample size for estimating the sensitivity or specificity of a diagnostic test with required precision and 95% confidence level. Sample size at 90% and 99% confidence level, respectively, can also be obtained by just multiplying 0.70 and 1.75 with the number obtained for the 95% confidence level. A nomogram instantly provides the required number of subjects by just moving the ruler and can be repeatedly used without redoing the calculations. This can also be applied for reverse calculations. This nomogram is not applicable for testing of the hypothesis set-up and is applicable only when both diagnostic test and gold standard results have a dichotomous category.
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              Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation.

              Wen-Yih I Tseng, Meng-Chuan Huang, Chien-Chiao Huang … (2011)
              This study aimed to assess the diagnostic accuracy and timeliness of using tracheal ultrasound to examine endotracheal tube placement during emergency intubation. This was a prospective, observational study, conducted at the emergency department of a national university teaching hospital. Patients received emergency intubation because of impending respiratory failure, cardiac arrest, or severe trauma. The tracheal rapid ultrasound exam (T.R.U.E.) was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the concordance between the T.R.U.E. and the capnography. A total of 112 patients were included in the analysis, and 17 (15.2%) had esophageal intubations. The overall accuracy of the T.R.U.E. was 98.2% (95% confidence interval [CI]: 93.7-99.5%). The kappa (κ) value was 0.93 (95% CI: 0.84-1.00), indicating a high degree of agreement between the T.R.U.E. and capnography. The sensitivity, specificity, positive predictive value, and negative predictive value of the T.R.U.E. were 98.9% (95% CI: 94.3-99.8%), 94.1% (95% CI: 73.0-99.0%), 98.9% (95% CI: 94.3-99.8%) and 94.1% (95% CI: 73.0-99.0%). The median operating time of the T.R.U.E. was 9.0s (interquartile range [IQR]: 6.0, 14.0). The application of the T.R.U.E. to examine endotracheal tube placement during emergency intubation is feasible, and can be rapidly performed. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
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                Author and article information

                Contributors
                Osman Adi
                Tan Wan Chuan
                Manikam Rishya
                Journal
                Journal ID (nlm-ta): Crit Ultrasound J
                Journal ID (iso-abbrev): Crit Ultrasound J
                Title: Critical Ultrasound Journal
                Publisher: Springer
                ISSN (Print): 2036-3176
                ISSN (Electronic): 2036-7902
                Publication date Collection: 2013
                Publication date (Electronic): 4 July 2013
                Volume: 5
                Issue: 1
                Page: 7
                Affiliations
                [1 ]Department of Trauma and Emergency Medicine, Raja Permaisuri Bainun Hospital, Ipoh, Perak 30990, Malaysia
                [2 ]Department of Trauma and Emergency Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
                Article
                Publisher ID: 2036-7902-5-7
                DOI: 10.1186/2036-7902-5-7
                PMC ID: 3772703
                PubMed ID: 23826756
                SO-VID: 5b50b9b5-e376-4277-87c9-893ed3172aaf
                Copyright © Copyright ©2013 Adi et al.; licensee Springer.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 5 March 2013
                Date accepted : 12 June 2013
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: bedside upper airway ultrasonography,endotracheal intubation,verification,waveform capnography
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: bedside upper airway ultrasonography, endotracheal intubation, verification, waveform capnography

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