Is a postintubation chest radiograph necessary in the emergency department?

Postintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR.

We seek to study the utility of postintubation CXR in ED patients.

This was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained.

A total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74-86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3-11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8-19) were judged to be too low with 10 (6.5%, 95% CI: 3-11) of these being right mainstem bronchus intubations. One patient (<1%, 95% CI:<0.0001-4) had a CXR confirming esophageal intubation.

ED intubations were judged to have "satisfactory" placement by CXR in 81% of patients. CXR is able to identify a small subset of patients that likely need immediate intervention based on their CXR. Until further studies refute the utility of postintubation CXR in ED intubations, they should remain a part of routine practice.