title: Where's the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement.
abstract: BACKGROUND
  The diagnosis of endotracheal tube (ETT) mal-position may be delayed in extreme environments. Several methods are utilized to confirm proper ETT placement, but these methods can be unreliable or unavailable in certain settings. Thoracic sonography, previously utilized to detect pneumothoraces, has not been tested to assess ETT placement.
  
  
  OBJECTIVE
  Thoracic sonography could correlate with pulmonary ventilation, and thereby, help to confirm proper ETT placement.
  
  
  METHODS
  Thirteen patients requiring elective intubation under general anesthesia, and data from two trauma patients were evaluated. Using a portable, hand-held, ultrasound (PHHU) machine, sonographic recordings of the chest wall visceral-parietal pleural interface (VPPI) were recorded bilaterally in each patient during all phases of airway management: (1) pre-oxygenation; (2) induction; (3) paralysis; (4) intubation; and (5) ventilation.
  
  
  RESULTS
  The VPPI could be well-imaged for all of the patients. In the two trauma patients, right mainstem intubations were noted in which specific pleural signals were not seen in the left chest wall VPPI after tube placement. These signs returned after correct repositioning of the ETT tube. In all of the elective surgery patients, signs correlating with bilateral ventilation in each patient were imaged and correlated with confirmation of ETT placement by anesthesiology.
  
  
  CONCLUSIONS
  This report raises the possibility that thoracic sonography may be another tool that could be used to confirm proper ETT placement. This technique may have merit in extreme environments, such as in remote, pre-hospital settings or during aerospace medical transports, in which auscultation is impossible due to noise, or capnography is not available, and thus, requires further scientific evaluation.
authors.affiliation: Department of Anesthesia, Foothills Medical Centre, Calgary, Alberta, Canada.
authors.forename: Rosaleen
authors.initials: R
authors.lastname: Chun
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
authors.forename: M
authors.initials: M
authors.lastname: Sirois
authors.forename: A E
authors.initials: AE
authors.lastname: Sargasyn
authors.forename: S
authors.initials: S
authors.lastname: Melton
authors.forename: D R
authors.initials: DR
authors.lastname: Hamilton
authors.forename: S
authors.initials: S
authors.lastname: Dulchavsky
mesh_terms: D004632:Emergency Medical Services; D004638:Emergency Treatment / Q000379:methods; D004867:Equipment Design; D004869:Equipment Safety; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods*; D008297:Male; D012494:Sampling Studies; D012680:Sensitivity and Specificity; D013909:Thorax / Q000000981:diagnostic imaging; D014132:Trachea / Q000000981:diagnostic imaging*; D018615:Ultrasonography, Doppler, Color