confirming ETT

 Q: Chest radiography (CXR) is the ideal way to rule out esophageal misplacement after tracheal intubation? 

A) True 

B) False 

 Answer: B 

 A single view CXR is more helpful to estimate the depth of the endo-tracheal-tube (ETT) but it is not the best way to exclude esophageal intubation. End-tidal carbon dioxide (ETCO2) is relatively a more reliable method to confirm ETT placement in the trachea in the non-cardiac arrest patient. Clinician should be aware that the esophagus also yields some detectable quantity of CO2 during the first few breaths. Five to six exhalations with a consistent CO2 exhalation is a reliable indicator of tracheal placement of ETT. 

This can be supplemented by other supportive (but not confirmatory) evidences such as '5-points' auscultation of breath and epigastric sounds, rise of the chest wall, condensation of the ETT, use of esophageal detector device (EDD), gently repassing the introducer through the ETT to feel the tracheal rings or carina, use of ultrasound and CXR.

Bronchoscope continue to be the gold standard to confirm ETT placement in cardiac and non-cardiac arrest patients

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References:

1. Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med 2002; 28:701.

2.  Jenkins WA, Verdile VP, Paris PM. The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med 1994; 12:413. 

3. Bair AE, Laurin EG, Schmitt BJ. An assessment of a tracheal tube introducer as an endotracheal tube placement confirmation device. Am J Emerg Med 2005; 23:754. 

4. Smith GM, Reed JC, Choplin RH. Radiographic detection of esophageal malpositioning of endotracheal tubes. AJR Am J Roentgenol 1990; 154:23. 

5. Chou HC, Tseng WP, Wang CH, et al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation 2011; 82:1279.