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AIRWAY VI

CONFIRMATION OF ENDOTRACHEAL TUBE POSITION IN EMERGENCY AIRWAY MANAGEMENT


Steven White, M.D.


I.

Excluding esophageal intubation:

A. Scope of the problem

1. incidence of unrecognized esophageal intubation

2. limits of visualization

a) vomitus/Blood/ inadequate suctioning

b) anatomic distortion/ positioning

3. limits of auscultation

a) poor air exchange (bronchospasm/ chest trauma/ pneumonia/ pulmonary edema)

b) pre-intubation ventilation with gastric distention= loss of "Gastric Gurgling" as sign of esophageal intubation

c) often increased ambient noise levels

B. Methods:

1. end-tidal CO2 - Qualitative (Nellcor) and Quantitative

2. esophageal Detector Device

3. lightwand

4. digital confirmation

5. endoscopic confirmation


II. Optimizing intratracheal position:


A. The problem with endobronchial intubation in the Emergency patient

1. increased risk of barotrauma

2. ventilation of non-perfused lung or collapsed lung (pneumothorax/ hemothorax) or contused lung

B. Optimum position relative to carina/glottis

1. 5 cm from carina

2. influence of head/neck position

3. limit of auscultation

a) unilaterally decreased breath sounds due to pathology

- Digital intubation predisposes to LEFT mainstem intubation

b) inablity to detect subtle ventilation differences with increased ambient noise

c) ETT at carina or just into mainstem bronchus can still transmit breath sounds to both lungs, but potential for

further endobronchial insertion with patient movement C. Methods for optimizing when x-ray not available

1. use and limitation of clinical positioning guidelines

- 23 cm in males/ 21 cm in females

2. lighted stylet

3. magnetic stylet

4. fiberoptic positioning


References:


Dailey RH, Simon B, Young GP, Stewart RD (eds) The Airway: Emergency Management. Mosby Yearbook, St. Louis, 1992.


Stewart RD: Digital Intubation in Dailey RH, Simon B, Young GP, Stewart RD (eds) The Airway: Emergency Management. Mosby Yearbook, St. Louis, 1992, pp 111-114.


Stewart RD: Lighted Stylet in Dailey RH, Simon B, Young GP, Stewart RD (eds) The Airway: Emergency Management. Mosby Yearbook, St. Louis, 1992, pp. 115-122.


Wolfe T: The Esophageal Detector Device: Summary of the current literature. Distributed by AMBU, Inc.


White SJ: Left mainstem intubation with digital intubation technique: An unrecognized risk. Am J Emerg Med July 1994; 12:466-468.


Stauffer JL, Olson DE, Petty TL: Complications and consequences of endotracheal intubation and tracheotomy. Am J Med 1981;70:65-76.


Brunel W, Coleman DL, Schwartz DE, et al: Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989; 96:1043-1045.


Bissinger U, Lenz G, Kuhn W: Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989; 18: 853-855.


White SJ and Slovis CM: Use of a magnetic intubation stylet and magnetic field sensor for endotracheal tube positioning (abstract). Ann Emerg Med 1993;22:955.


Dronen S, Chadwick O, Nowak R: Endotracheal Tip Position in the Arrested Patient (letter). Ann Emerg Med Feb 1982;11:116-117.



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