Comparison of three point-of-care ultrasound techniques to confirm endotracheal tube placement: A randomized clinical...

Rapid confirmation of the endotracheal tube (ETT) position following emergency intubation is crucial, but traditional methods have limitations in this setting. Although ultrasonographic techniques are highly accurate, studies comparing them are limited. In this study, we aimed to compare the diagnostic performance and speed of three different point-of-care ultrasound (POCUS) techniques for confirming ETT position.

We conducted a single-center, prospective, randomized clinical trial in the emergency department of a university hospital. Adults undergoing rapid sequence intubation were randomly assigned to transtracheal ultrasound (TUS), lung-sliding ultrasound (LUS), or diaphragm ultrasound (DUS) with 1:1:1 allocation ratio. The primary outcome was ETT location (tracheal or esophageal), determined by waveform capnography and auscultation. We also measured intubation time and the time needed for each confirmation method.

Of 217 patients screened, 200 were randomized to TUS (n = 66), LUS (n = 67), or DUS (n = 67), and all were included in the primary analysis. The median age was 75 years (IQR 63-84), and 54.5% were male. Esophageal intubation occurred in 14% (n = 28) of patients. For tracheal placement detection, sensitivity and specificity were 98.2% (95% CI, 90.4% to 100.0%) and 100.0% (95% CI, 69.2% to 100.0%) for TUS, 98.2% (95% CI, 90.6% to 100.0%) and 100.0% (95% CI, 69.2% to 100.0%) for LUS, and 96.6% (95% CI, 88.3% to 99.6%) and 87.5% (95% CI, 47.3% to 99.7%) for DUS, with no between-group difference in accuracy (p = 0.44). Confirmation times were 4.6 s (IQR, 3.3-6.0) for TUS, 9.4 s (IQR, 7.3-12.2) for LUS, and 13.4 s (IQR, 11.8-15.1) for DUS (p < 0.001). Auscultation took a median of 11.5 s (IQR 9.4-13.9), and obtaining five capnography waveforms took 17.0 s (IQR 14.2-20.6).

All three ultrasound techniques demonstrated high diagnostic performance for confirming ETT location after rapid sequence intubation, with TUS providing the shortest confirmation time.

ClinicalTrials.gov Identifier: NCT06656546.