5-Point Airway Ultrasound Protocol may revolutionize Pediatric Intubation, study suggests

Confirming the correct placement of an endotracheal tube is crucial in pediatric patients due to their low tolerance to oxygen deprivation from esophageal intubation or incorrect tube positioning. Airway ultrasonography is recognized for its ability to confirm the placement of the endotracheal tube across various age groups in emergency and intensive care settings. Recent study evaluated the performance of a 5-point airway ultrasound (5-AIR USG) protocol in confirming endotracheal intubation (ETI) and endotracheal tube (ETT) positioning (ETP) in 75 pediatric patients undergoing elective surgery.

Protocol Description

The 5-AIR USG protocol involved real-time tracheal ultrasound scanning followed by bilateral pleural and diaphragmatic ultrasound scanning. The primary objective was to estimate the diagnostic sensitivity of the 5-AIR USG protocol for detecting correct (endotracheal) versus incorrect (endobronchial) ETP. Secondary objectives included estimating the accuracy of the protocol for detecting ETI (tracheal versus esophageal), comparing the time required for confirmation of ETI and ETP by the USG protocol versus quantitative waveform capnography (QWC) and 5-point auscultation, and determining the quality of visualization (QOV) score for each component of the USG protocol.

Study Findings

The study found that there were no esophageal intubations, so the accuracy of the USG protocol for ETI could not be determined. For ETP, the 5-AIR USG protocol identified 4 out of 7 endobronchial placements, resulting in a sensitivity of 100%, specificity of 57.14%, and an overall diagnostic accuracy of 96%. The mean time for confirmation of ETI by QWC was significantly longer than real-time tracheal USG (20.77 s vs 2.11 s). For ETP, the mean time for 5-point auscultation was 12.69 s versus 6.39 s for pleural USG. Adding diaphragmatic scanning increased the time to 11.45 s, and 30.68 s if a probe change was required. The 5-AIR USG protocol demonstrated high diagnostic accuracy to confirm endotracheal intubation and position in pediatric patients, though the specificity for ETP was relatively low. The protocol was faster than QWC for confirming ETI and comparable to 5-point auscultation for ETP, except when a probe change was required. The study suggests that the 5-AIR USG protocol may be a useful adjunct to clinical signs, auscultation, and QWC to confirm endotracheal intubation and position.

Key Points

1. The study evaluated the performance of a 5-point airway ultrasound (5-AIR USG) protocol in confirming endotracheal intubation (ETI) and endotracheal tube (ETT) positioning (ETP) in 75 pediatric patients undergoing elective surgery.

2. The 5-AIR USG protocol involved real-time tracheal ultrasound scanning followed by bilateral pleural and diaphragmatic ultrasound scanning. The primary objective was to estimate the diagnostic sensitivity of the 5-AIR USG protocol for detecting correct (endotracheal) versus incorrect (endobronchial) ETP. Secondary objectives included estimating the accuracy of the protocol for detecting ETI (tracheal versus esophageal), comparing the time required for confirmation of ETI and ETP by the USG protocol versus quantitative waveform capnography (QWC) and 5-point auscultation, and determining the quality of visualization (QOV) score for each component of the USG protocol.

3. The study found that there were no esophageal intubations, so the accuracy of the USG protocol for ETI could not be determined. For ETP, the 5-AIR USG protocol identified 4 out of 7 endobronchial placements, resulting in a sensitivity of 100%, specificity of 57.14%, and an overall diagnostic accuracy of 96%.

4. The mean time for confirmation of ETI by QWC was significantly longer than real-time tracheal USG (20.77 s vs 2.11 s). For ETP, the mean time for 5-point auscultation was 12.69 s versus 6.39 s for pleural USG. Adding diaphragmatic scanning increased the time to 11.45 s, and 30.68 s if a probe change was required.

5. The 5-AIR USG protocol demonstrated high diagnostic accuracy to confirm endotracheal intubation and position in pediatric patients, though the specificity for ETP was relatively low.

6. The study suggests that the 5-AIR USG protocol may be a useful adjunct to clinical signs, auscultation, and QWC to confirm endotracheal intubation and position.

Reference –

Adhiraj Baruah et al. (2024). 5-Point Airway (5-AIR) Ultrasound Protocol For Confirmation Of Endotracheal Intubation And Position In Paediatric Patients Undergoing Surgery: A Prospective Observational Study. *Indian Journal Of Anaesthesia*.https://doi.org/10.4103/ija.ija_682_24.