ABSTRACT
SUMMARY:
Confirming proper intubation in the emergency setting
Contents Bibliography:
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3 Bozeman, W. P., D. Hexter, et al. (1996). “Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation.” Ann Emerg Med 27(5): 595-9.
5 Jenkins, W. A., V. P. Verdile, et al. (1994). “The syringe aspiration technique to verify endotracheal tube position.” Am J Emerg Med 12(4): 413-6.
Bozeman, W. P., D. Hexter, et al. (1996). “Esophageal detector device versus detection of
end-tidal carbon dioxide level in emergency intubation.” Ann Emerg Med
27(5): 595-9.
STUDY OBJECTIVES: To confirm the ability of the esophageal detector device (EDD) to indicate positioning of endotracheal tubes (ETTs) in patients intubated under emergency conditions and to compare the performance of the EDD with that of end-tidal carbon dioxide (ETCO2). METHODS: This single-subject study comprising a prospective case series was conducted in the emergency department of an urban university hospital. All adult patients were intubated either in the ED or by paramedics in the field. ETT position was initially evaluated by means of auscultation, then EDD, and, finally, spectrographic qualitative ETCO2 monitoring in each patient. Discrepancies between the EDD and ETCO2 results were resolved by means of direct laryngoscopy. RESULTS: In 100 intubated patients, both the EDD and ETCO2 monitoring detected the single esophageal intubation that occurred. Of the remaining 99 tracheal intubations, the EDD correctly indicated tracheal placement in 98 (sensitivity, 99%) and was indeterminate in 1 case because of blockage of the ETT by secretions resulting from pulmonary edema. By comparison, ETCO2 monitoring correctly indicated tracheal placement in 86 cases (sensitivity, 87%) and was incorrect in 13 cases (P .01). ETCO2 monitoring failed in 2 patients with pulmonary edema and in 11 patients with cardiac arrest. Among the 37 patients in the cardiac arrest group, the EDD correctly indicated ETT placement in 37 patients (sensitivity, 100%). In contrast, ETCO2 monitoring correctly indicated ETT placement in 26 patients (sensitivity, 70%; P .01). CONCLUSION: The EDD reliably confirms tracheal intubation in the emergency patient population. The EDD is more accurate than ETCO2 monitoring in the overall emergency patient population because of its greater accuracy in cardiac arrest patients.
Kasper, C. L. and S. Deem
(1998). “The self-inflating bulb to detect esophageal
intubation during emergency airway management.” Anesthesiology 88(4):
898-902.
BACKGROUND: The negative-pressure test using a self-inflating bulb (SIB) during emergency intubation was studied to determine its reliability and predictive value in this setting. METHODS: The endotracheal tube (ETT) position was tested in 300 consecutive patients undergoing in-hospital emergency endotracheal intubation. Immediately after intubation and before ETT cuff inflation, the following protocol was strictly followed: (1) an SIB was compressed, connected to the ETT, and released. A 10-s period was allowed for the bulb to inflate. (2) The ETT cuff was inflated, and the ETT position was confirmed using colorimetric or infrared carbon dioxide detection, or both, combined with clinical evaluation. RESULTS: There were 19 esophageal intubations (6% incidence). The SIB correctly identified all patients with esophageal intubation (sensitivity, 100%) and correctly identified all but three ETTs placed in the trachea (specificity, 99%). The three tracheally placed tubes that were misidentified by the bulb syringe occurred during one case each of chronic obstructive pulmonary disease, copious secretions, and obesity; of note were three tracheally placed tubes that were misidentified by the carbon dioxide analyzers during cardiopulmonary resuscitation. CONCLUSIONS: The SIB proved to be a sensitive and specific test for esophageal intubation in the emergency setting when used according to the protocol described, and it is complementary to carbon dioxide detection. The predictive value of the bulb syringe appears to be improved when a prolonged period for reinflation is allowed. It holds particular promise because of its low cost and portability.
Jenkins, W. A., V. P. Verdile, et al. (1994). “The syringe aspiration technique to verify endotracheal tube
position.” Am J Emerg Med 12(4): 413-6.
This prospective, clinical study was performed to determine the utility of the syringe aspiration technique (SAT) to verify endotracheal tube (ETT) position. Ninety consecutive patients requiring urgent intubation in the emergency department or prehospital setting were enrolled in the study. The SAT correctly identified intratracheal ETT placement in 88 patients and esophageal misplacement in 2 patients. Ultimately, standard detection techniques were used to confirm ETT placement. The SAT was an accurate means of verifying ETT placement.
Schaller, R. J., J. S. Huff,
et al. (1997). “Comparison of a colorimetric end-tidal CO2
detector and an esophageal aspiration device for verifying endotracheal tube
placement in the prehospital setting: a six-month experience.” Prehospital
Disaster Med 12(1): 57-63.
INTRODUCTION: Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest. HYPOTHESIS: The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device. METHODS: This was prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric end-tidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study. RESULTS: There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the end-tidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p < 0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized. CONCLUSION: The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.
Tanigawa, K., T. Takeda, et al. (2000). “Accuracy and reliability of the self-inflating bulb to verify
tracheal intubation in out-of-hospital cardiac arrest patients.”
Anesthesiology 93(6): 1432-6.
BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients. METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation). RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity. CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.
Kapsner, C. E., D. C.
Seaberg, et al. (1996). “The esophageal detector device:
accuracy and reliability in difficult airway settings.” Prehospital Disaster
Med 11(1): 60-2.
INTRODUCTION: The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult. METHODS: This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET-tube placement using the EDD in five swine in respiratory arrest. The ET tube was place in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest. RESULTS: There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in the determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present. CONCLUSIONS: The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device.
MacLeod, B. A., M. B. Heller,
et al. (1991). “Verification of endotracheal tube placement
with colorimetric end-tidal CO2 detection.” Ann Emerg Med 20(3):
267-70.
STUDY OBJECTIVE: To determine the ability of a disposable colorimetric CO2 detector to accurately confirm or refute endotracheal tube placement. DESIGN: Two hundred fifty prospective emergency intubations. SETTING: Emergency intubations performed in the emergency department, helicopter, and prehospital ground environment. TYPE OF PARTICIPANTS: Intubations were performed by emergency medicine residents, paramedics, and flight nurses. INTERVENTIONS: The FEF CO2 detector was applied after 250 emergency intubations. Notation of color change indicating intratracheal placement was recorded in each case. Confirmation of refutation of the detector's results was determined subsequently through traditional methods. RESULTS: The sensitivity for confirmation of endotracheal intubation in the 137 patients with a palpable pulse was 100%. However, only 76 of 103 patients (sensitivity, 72%) in cardiac arrest had endotracheal intubation confirmed by color change. The device was uniformly specific for tracheal intubation in 73 arrested patients in whom a color change was noted (100%). There was one instance (of a total of seven misintubations) in which a positive color change was noted, but the tube was not intratracheal (specificity, 86%). Overall sensitivity for tracheal intubation was 88% (95% confidence limits; range, 0.83 to 0.92), and specificity for tracheal intubation was 92% (95% confidence limits; range, 0.62 to 0.99). CONCLUSION: The FEF colorimetric detector reliably detects intratracheal placement in the nonarrested patient. Its use in prolonged cardiac arrest merits further study.