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