Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study

Abstract

Introduction: The chest X-ray (CXR) is the standard of practice to assess the tip of the endotracheal tube (ETT) in ventilated children. In many hospitals, it takes hours to get a bedside CXR, and it has radiation exposure. The objective of this study was to find the utility of bedside ultrasound (USG), in assessing the ETT tip position in a Pediatric Intensive Care Unit (PICU).

Methods: It was a prospective study conducted in the PICU of a tertiary care center involving 135 children aged from 1 month to 60 months, requiring endotracheal intubation. In this study, the authors compared the position of the ETT tip by the CXR (gold standard) and USG. The CXR was taken in children to assess the correct position of the tip of ETT. The USG was used to measure the distance between the tip of ETT and the arch of the aorta, thrice in the same patient. The mean of the three USG readings was compared with the distance between the tip of the ETT and carina in CXR.

Results: The reliability of three USG readings was tested by absolute agreement coefficient in intraclass correlation (ICC), 0.986 (95% CI: 0.981-0.989). The sensitivity and specificity of the USG in identifying the correct position of the ETT tip in children when compared to CXR were 98.10% (95% CI: 93.297-99.71%) and 50.0% (95% CI: 31.30-68.70%), respectively.

Conclusion: In ventilated children <60 months of age, identifying the tip of ETTs by bedside the USG has good sensitivity (98.10%) but poor specificity (50.0%).

How to cite this article: Subramani S, Parameswaran N, Ananthkrishnan R, Abraham S, Chidambaram M, Rameshkumar R, et al. Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study. Indian J Crit Care Med 2022;26(11):1218-1224.

Keywords: Bedside ultrasound; Children; Endotracheal tube tip position.

Flowchart 1

Flow diagram showing screening, eligibility and available for analysis; ETT, endo tracheal tube; ICP, intra cranial pressure; USG, ultrasound

Figs 1A and B

(A) Showing the position of neck while taking CXR (Black line arrow showing the X-ray cassette; (B) Showing the position of neck while taking the USG. Note the probe is kept in the right supraclavicular area to visualize the ETT

Figs 2A and B

USG images of trachea and arch of aorta from the neck (A) USG showing bullet sign formed by ETT (line arrow at the apex) and posterior air column in trachea (solid arrow), showing that ETT is inside trachea. The trace of the air column looks like a bullet- “Bullet sign”; (B) USG showing arch of aorta (solid arrow) and left common carotid artery (line arrow). Note the pulsatile wave form of aortic arch in pulse wave doppler

Figs 3A and B

USG image of ETT and corresponding CXR image; (A) USG image showing the distance between the tip of ETT and superior border arch of aorta. Line arrow shows the ETT and solid arrow shows the arch of aorta; (B) CXR showing the distance between the tip of ETT (line arrow) and carina (solid arrow)