title: Auscultation versus Point-of-care Ultrasound to Determine Endotracheal versus Bronchial Intubation: A Diagnostic Accuracy Study.
abstract: BACKGROUND
  Unrecognized malposition of the endotracheal tube (ETT) can lead to severe complications in patients under general anesthesia. The focus of this double-blinded randomized study was to assess the accuracy of point-of-care ultrasound in verifying the correct position of the ETT and to compare it with the accuracy of auscultation.
  
  
  METHODS
  Forty-two adult patients requiring general anesthesia with ETT were consented. Patients were randomized to right main bronchus, left main bronchus, or tracheal intubation. After randomization, the ETT was placed via fiber-optic visualization. Next, the location of the ETT was assessed using auscultation by a separate blinded anesthesiologist, followed by an ultrasound performed by a third blinded anesthesiologist. Ultrasound examination included assessment of tracheal dilation via cuff inflation with air and evaluation of pleural lung sliding. Statistical analysis included sensitivity, specificity, positive predictive value, negative predictive value, and interobserver agreement for the ultrasound examination (95% CI).
  
  
  RESULTS
  In differentiating tracheal versus bronchial intubations, auscultation showed a sensitivity of 66% (0.39 to 0.87) and a specificity of 59% (0.39 to 0.77), whereas ultrasound showed a sensitivity of 93% (0.66 to 0.99) and specificity of 96% (0.79 to 1). Identification of tracheal versus bronchial intubation was 62% (26 of 42) in the auscultation group and 95% (40 of 42) in the ultrasound group (P = 0.0005) (CI for difference, 0.15 to 0.52), and the McNemar comparison showed statistically significant improvement with ultrasound (P < 0.0001). Interobserver agreement of ultrasound findings was 100%.
  
  
  CONCLUSIONS
  Assessment of trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the location of ETT.
authors.affiliation: From the Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (D.R., E.F., R.H., J.S., K.M.G., E.B., J.R.); and Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Irvine, Los Angeles, California (M.C.).
authors.forename: Davinder
authors.initials: D
authors.lastname: Ramsingh
authors.forename: Ethan
authors.initials: E
authors.lastname: Frank
authors.forename: Robert
authors.initials: R
authors.lastname: Haughton
authors.forename: John
authors.initials: J
authors.lastname: Schilling
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Gimenez
authors.forename: Esther
authors.initials: E
authors.lastname: Banh
authors.forename: Joseph
authors.initials: J
authors.lastname: Rinehart
authors.forename: Maxime
authors.initials: M
authors.lastname: Cannesson
mesh_terms: D000328:Adult; D000368:Aged; D058109:Airway Management / Q000379:methods; D000768:Anesthesia, General; D001314:Auscultation / Q000379:methods*; D001980:Bronchi / Q000000981:diagnostic imaging; D018592:Cross-Over Studies; D004311:Double-Blind Method; D005260:Female; D005336:Fiber Optic Technology; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D014132:Trachea / Q000000981:diagnostic imaging; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods*