Are ultrasounds as safe as chest radiographs at assessing complications of endotracheal 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 multidisciplinary 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 CXRand 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.

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.