Document Detail

A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal tube position in a pediatric emergency department.
MedLine Citation:
PMID:  19414520     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Investigators report endotracheal tube misplacement in up to 40% of emergent intubations. The standard elements of confirmation have significant limitations. Diaphragmatic ultrasound is a potentially viable addition to the confirmatory process. Our primary hypothesis is that ultrasound is equivalent to chest radiography in determining endotracheal tube position within the airway in emergent pediatric intubations. METHODS: We enrolled a prospective, convenience sample from all intubated patients in our emergency department. The primary outcome was the agreement between diaphragmatic ultrasound and chest radiography for endotracheal tube position. On ultrasound, tracheal placement equaled bilateral diaphragmatic motion, bronchial placement equaled unilateral diaphragmatic motion, and esophageal placement equaled no or paradoxical diaphragmatic motion during delivery of positive pressure. Study sonographers were blind to radiographic results. Our secondary outcome was the timeliness of ultrasound versus chest radiography results. Our institutional review board approved this study with a waiver of informed consent. RESULTS: One hundred twenty-seven patients were enrolled. In 24 (19%) patients, the endotracheal tube was in the mainstem bronchus on chest radiography. There were no esophageal intubations in the sample. Ultrasound and chest radiography agreed on endotracheal tube placement in 106 patients (94 tracheal and 12 mainstem), for an overall agreement of 0.83. The sensitivity of ultrasound for tracheal placement was 0.91. The specificity of ultrasound for mainstem intubation was 0.50. Thirty-four patients had a second ultrasound by a separate, blinded sonographer; 33 of 34 of the results of the second sonographer were in agreement with the initial sonogram, for an interrater agreement of 97%. Clinically useful chest radiography results took a median of 8 minutes longer to achieve than ultrasound results. CONCLUSIONS: Diaphragmatic ultrasound was not equivalent to chest radiography for endotracheal tube placement within the airway. However, ultrasound results were timelier, detected more misplacements than standard confirmation alone, and were highly reproducible between sonographers.
Benjamin Thomas Kerrey; Gary Lee Geis; Andrea Megan Quinn; Richard William Hornung; Richard Michael Ruddy
Publication Detail:
Type:  Comparative Study; Journal Article     Date:  2009-05-04
Journal Detail:
Title:  Pediatrics     Volume:  123     ISSN:  1098-4275     ISO Abbreviation:  Pediatrics     Publication Date:  2009 Jun 
Date Detail:
Created Date:  2009-06-01     Completed Date:  2009-06-17     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0376422     Medline TA:  Pediatrics     Country:  United States    
Other Details:
Languages:  eng     Pagination:  e1039-44     Citation Subset:  AIM; IM    
Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229-3039, USA.
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MeSH Terms
Academic Medical Centers
Bronchi / ultrasonography
Child, Preschool
Clinical Competence / standards
Diaphragm / ultrasonography*
Emergency Medicine / education
Emergency Service, Hospital*
Inservice Training*
Intubation, Intratracheal*
Medical Errors
Observer Variation
Predictive Value of Tests
Prospective Studies
Radiography, Thoracic*
Respiratory Therapy / education
Sensitivity and Specificity
Time and Motion Studies
Trachea / ultrasonography

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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