Anyone interested in exploring novel ways of monitoring the appropriate position of endotracheal tube (ETT) in mechanically ventilated ICU patients?
Traditionally this is done with repeated Chest X-rays. What about researching new available technologies, like ultrasound or wireless methods, without the potential hazards of repeated radiation?
Dear Dr. Mohamad-Hani Temsah , it's an interesting initiative! USG is already in vogue at some centres Article Reliability of Ultrasonography in Confirming Endotracheal Tu...
and wireless devices are coming up. And, MIT researchers have been developing a wireless ETT position monitoring device (literature attached below). You can try to arrange that and go forward with... Regards- Rabiul.
Thanks Rabiul for your enlightening comments. Could you please share the link to the article , as I can't open the PDF ..
Sure...
http://web.mit.edu/2.75/projects/IEEE_EMBS_2008_Wichakool.pdf
Thanks Rabul.
Going through this 2008 paper led me to newer prototype on Google patents:
https://patents.google.com/patent/US8457715B2/en
I think that this device has limitations. Its accuracy may vary with the training and experience of the user. I am concerned about the position of the endotracheal tube relative to the level of the patient's carina and vocal cords. If this device is used, then an initial CXR needs to be performed to determine proper placement, at the same time as this ultrasound is performed so that comparison can be made and monitored, and a method to track the position of the magnet placement must be developed, and practiced consistently. (Would we describe the placement or would we "Mark it with a sharpie"?)
The CXR is used in the ICU to monitor more than the position of the ETT. CXR provides significantly more information about the lungs and heart than this single device will. I question the usefulness of this device on a consistent basis. It may be more useful when used if the airway is in question.
There is another possibility:
We now have single patient use bronchoscopes which have a small camera at the handle or are attached to a video screen that is about 5" x 7" .
Those can be inserted through an adapter at the ventilator connection to the ETT, and are very useful in visualizing more than just the position of the ETT. If appropriate for your facility, these may be able to be stored in the patient room, for repeated use on the same patient. I have not researched the feasibility of multiple uses for this piece of equipment.
The following is hard to describe in print:
Finally, if you auscultate over the sternum: First remove a small amount of air from the cuff for minimal leak, listen over the sternum for the position of the leak. That should be the approximate level of the cuff. The cuff is in the same place for the same size of ETT. You can approximate the level of the tip of the ETT by including the cm from the cuff to the tip. However, you will still not know the exact position of the tip of the ETT relative to the carina or the vocal cords.
The issue is more challenging in neonates and infants, as a small change of the ETT (0.5 - 1 cm) can be associated with the adverse event of right main bronchus intubation or self extubation .
Absolutely, my suggestions were directed at the adult population.
In a preemie, simply turning the head can cause right mainstem placement or extubation.
It is too bad that we can not use transillumination.
I will consider this further now that I now the patient population.
Other than its use in determination of cardiac anomalies, I am unfamiliar with other uses of ultrasound in Neonates/Preemies. I assume that ultrasound could show the carina as well? Placement of the ETT relative to the carina is an important consideration. If this is possible, and it could be easily and quickly done by a skilled practitioner, with a minimal disruption of the fragile preemie, it could become standard of care. Can an ultrasound already detect the placement of the ETT, with the ETTs currently in use?
I wanted to clarify my response above, I do know that ultrasound is used for more than cardiac anomalies.
Dear Polly Dendy , yes, USG is already being used to detect ETT position in many centers with necessary expertise by the interventionists. Of course, the supportive options like direct visualization, capnography etc may be adopted in exclusively difficult plus suspected scenarios. You may please go through this related paper: Article Reliability of Ultrasonography in Confirming Endotracheal Tu...
Regards- Rabiul