The assessment of three methods to verify tracheal tube placement in the emergency setting

      Abstract

      We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO2) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO2 monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one false-positive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n=56), auscultation, the ETCO2, and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P<0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n=81), auscultation, the ETCO2, and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P<0.05 vs. EDD and ETCO2). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO2 monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO2 or the EDD are not uncommon, and clinical methods are superior to the use of these devices.

      Sumàrio

      Estudamos prospectivamente a fiabibilidade de dois os métodos clı́nicos, detecção de dióxido de carbono no fim da expiração (ETCO2) e o uso do aparelho de detecção esofágica (EDD) para verificar a entubação traqueal em 137 adultos no departamento de emergência. A posição do tubo endotraqueal foi testada imediatamente após entubação com o EDD e pelo monitor ET CO2, seguida de auscultação torácica. A visualização por laringoscopia foi classificada de acordo com os graus de Cormack. Ocorreram 13 entubações esofágicas tendo-se verificado um falso positivo no teste EDD e na auscultação. Nos doentes que não fizeram paragem cardı́aca (n=56), a auscultação, o ETCO2, e o teste EDD identificaram correctamente respectivamente 92.6**, 67.9, e 75.3% das entubações traqueais (**, P<0.05 vs EDD e ETCO2). A frequência dos graus 1 e 2 de Cormack foram de 83.9% no grupo sem paragem cardı́aca, e 95.1% nos doentes com paragem cardı́aca. Em conclusão, a monitorização do ETCO2 foi o método mais fiável para confirmar a entubação traqueal nos doentes que não estavam em paragem cardı́aca. Contudo durante a paragem cardı́aca e a reanimação cardiopulmonar não são raros os resultados negativos pelo ETCO2 ou o EDD, e os métodos clı́nicos são superiores ao uso destes aparelhos.

      Resumen

      Estudiamos en forma prospectiva la confiabilidad de los métodos clı́nicos, la detección de dióxido de carbono espiratorio (ETCO2), el dispositivo detector esofágico (EED) para verificar la intubación traqueal en 137 pacientes adultos en el departamento de emergencias. Se probó la posición del tubo endotraqueal, inmediatamente después de intubar, por medio de EDD, monitor de ETCO2, seguido por la auscultación del tórax. Las visiones obtenidas por la laringoscopı́a fueron clasificadas por la escala de Cormarc. De las 13 intubaciones esofágicas ocurridas, se obtuvo un falso positivo con EDD y auscultación. En los pacientes que no se encuentran en paro cardı́aco, la auscultación, la detección de ETCO2, y prueba con EDD identificaron correctamente 89.3, 98.6 y 94.6% de las intubaciones traqueales, respectivamente (*, P<0.05 vs. pacientes de paro cardı́aco). En pacientes en paro cardı́aco (n=81), la auscultación, la detección de ETCO2, y la prueba con EDD identificaron correctamente 92.6**, 67.9 y 75.3% de las intubaciones traqueales, respectivamente (**, P<0.05 vs EDD y ETCO2). La frecuencia de Cormack grado 1 o 2 fue 83.9% en el grupo sin paro cardı́aco, y de 95.1% en los pacientes en paro cardı́aco. En conclusión, el monitoreo de ETCO2 es el método mas confiable de verificar la intubación traqueal en pacientes que no se encuentran en paro cardiorrespiratorio. Durante el paro cardiorrespiratorio y la reanimación cardiopulmonar, sin embargo, no son infrecuentes resultados negativos al usar ETCO2 o EDD, y los métodos clı́nicos son superiores al uso de estos dispositivos.

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