Visualizing an ETT on Ultrasound

Written by: Dr. Seldon Davis

Edited by: Dr. Joann Hsu



The case:

60 M with pmh HTN, DM, COPD, smoking history, presents with 3 days of worsening SoB and productive cough. He arrives in moderate respiratory distress with retractions, speaking in 3 word sentences.

Patient gets intubated.

Portable xray is delayed.

How can we confirm ETT placement on ultrasound?



Probe Choice ---> Curvilinear vs Linear

  1. Probe Placement ---> lateral to vs mid Suprasternal notch  

  2. Poor image quality? ---> focus on the changes through motion

    1. Changes should be seen in the trachea itself, never off laterally (in the esophagus)

    2. Looks like there are two tracheas? Tube has likely been Goosed :(



“Double Trachea Sign” = esophageal intubation :(

Tracheal vs Bronchial intubation

Try to Identify Balloons location w/ US 

  1. inflate/deflate and check for motion, or fill balloon w/ saline and try to visualize changes on US machine

  2. Post-intubation Lung POCUS 

    1. look for bilateral lung sliding

Bonus:

CRIC ANATOMY

References

  1. Dennington, D., Vali, P., Finer, N. N., & Kim, J. H. (2012). Ultrasound confirmation of endotracheal tube position in neonates. Neonatology, 102(3), 185-189.

  2. Gottlieb, M., Holladay, D., Burns, K. M., Nakitende, D., & Bailitz, J. (2020). Ultrasound for airway management: an evidence-based review for the emergency clinician. The American journal of emergency medicine, 38(5), 1007-1013.

  3. Gottlieb, M., Holladay, D., & Peksa, G. D. (2018). Ultrasonography for the confirmation of endotracheal tube intubation: a systematic review and meta-analysis. Annals of emergency medicine, 72(6), 627-636.

  4. Lahham, S., Wilson, S. P., Turner, E., Subeh, M., Rosen, M. A., Youssefian, A., ... & Fox, J. C. (2018). Three-window ultrasonography confirmation of endotracheal tube placement. Research in Cardiovascular Medicine, 7(4), 192-196.

  5. Muslu B, Sert H, Kaya A, et al. Use of sonography for rapid identification of esophageal and tracheal intubations in adult patients. J Ultrasound Med. 2011;30:671-676

  6. Sahu, A. K., Bhoi, S., Aggarwal, P., Mathew, R., Nayer, J., Mishra, P. R., & Sinha, T. P. (2020). Endotracheal tube placement confirmation by ultrasonography: a systematic review and meta-analysis of more than 2500 patients. The Journal of Emergency Medicine, 59(2), 254-264.


Booth EM