- Email: [email protected]
The utility of ultrasonography to confirm proper endotracheal tube placement in neonates
Accepted Manuscript Title: The utility of ultrasonography to confirm proper endotracheal tube placement in neonates Authors: Shyh-Shyong Sim MD Jen-Tang Sun MD Chieh-Min Fan MD, MSc Kuang-Chau Tsai MD, MSc PII: DOI: Reference:
S0300-9572(16)30137-X http://dx.doi.org/doi:10.1016/j.resuscitation.2016.06.030 RESUS 6841
To appear in:
Resuscitation
Received date: Accepted date:
21-6-2016 23-6-2016
Please cite this article as: Sim S-S, Sun J-T, Fan C-M, Tsai K-C, The utility of ultrasonography to confirm proper endotracheal tube placement in neonates, Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.06.030 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Letter to the Editor
The utility of ultrasonography to confirm proper endotracheal tube placement in
ip t
neonates
cr
Shyh-Shyong Sim*, MD, Jen-Tang Sun, MD, Chieh-Min Fan, MD, MSc, Kuang-
us
Chau Tsai, MD, MSc
an
Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan Correspondent author
M
*
nil
Financial support:
nil
Financial disclosure:
the authors have no connection to any companies or products
te
d
Conflict of interest:
Ac ce p
mentioned in the article
Word count:
494
words
Address for reprints:
Shyh-Shyong Sim, MD.
Department of Emergency Medicine, Far Eastern Memorial Hospital No.21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan Tel: 886-2- 8966-7000 Ext 1125 Email: [email protected] or [email protected]
1 Page 1 of 9
Correspondent author: Shyh-Shyong Sim, MD.
ip t
Department of Emergency Medicine, Far Eastern Memorial Hospital
Tel: 886-2- 8966-7000 Ext 1125
Ac ce p
te
d
M
an
us
Email: [email protected] or [email protected]
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No.21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan
2 Page 2 of 9
Letter to the Editor
The utility of ultrasonography to confirm proper endotracheal tube placement in
ip t
neonates
cr
Sir,
us
Using physical examination to confirm the endotracheal tube placement on a neonate
an
is never an easy task, especially in the chaotic resuscitation scenario. By our own experience, we proposed the usage of bedside ultrasonography to confirm proper
M
endotracheal tube placement in a timelier manner.
d
An obstetrician rushed in our emergency department around midnight, he’s holding a
te
newborn baby, giving mouth to nose and mouth ventilation to the baby. The baby was cyanotic and appeared flaccid. We took over the baby and put on a bag-valve-mask
Ac ce p
for positive ventilation. According to the obstetrician, the baby was just delivered, appearing apnea and cyanotic, he brought the baby to our emergency department immediately. Electrocardiogram showed the baby’s heart rate was around 50 bpm, we started chest compression immediately and prepared for endotracheal intubation. Since we had no specific body weight and body height of the newborn, we used Broselow Pediatric Emergency Tape to guide medication dosages and the size of equipment. We inserted a 3.0 endotracheal tube and fixed the tube at 10.5cm depth. Soon after the ventilation established, baby’s heart rate returned to 120 bpm with pulse. Baby’s cyanosis resolved but still remained pale. Pulse oximeter showed SpO2 90%. We
3 Page 3 of 9
checked bilateral breath sound and the expansion of chest wall to confirm the placement of endotracheal tube, there was no noticeable difference of both sides. Upon waiting for portable chest radiography to check the position of endotracheal
ip t
tube, we used a bedside ultrasonography to check lung sliding sign over bilateral midaxillary line. We found presence of lung sliding over right side (Fig.1A, B) but
cr
absence over left side (Fig.1C, D), there was presence of lung pulse over left side. The finding showed that there was adequate ventilation over right lung, indicating we
us
might do a right main-stem intubation. Soon after the portable chest radiograph taken,
an
we relocated endotracheal tube, and rechecked bilateral lung sliding sign, after confirming presence of bilateral lung sliding signs, we fixed the endotracheal tube at
M
8cm depth. Baby’s SpO2 became 100% and skin became pinkish. Later, the chest radiograph taken earlier, revealed the position of endotracheal tube, which was a right
d
main-stem intubation (Fig.1 E). The finding of chest radiography coincides with our
te
assessment through ultrasonography examination.
Ac ce p
This experience indicated that bedside ultrasonography is a feasible and timely tool for confirmation of proper endotracheal tube placement in neonates. Previous study compared diaphragmatic ultrasonography with chest radiography in determine endotracheal tube position in pediatrics, showing that diaphragmatic ultrasonography was not equivalent to chest radiography but was a timelier manner.1 Recent study
demonstrated the main ultrasound findings of neonatal pulmonary atelectasis is the absence of lung sliding and presence of lung pulse.2 Our previous study proposed the
usage of ultrasonography lung sliding signs in confirming proper endotracheal tube in adults.3 In addition, tracheal rapid ultrasound saline test is not applicable in neonates.4
4 Page 4 of 9
We strongly encourage further study to validate the usage of ultrasonography lung
Ac ce p
te
d
M
an
us
cr
ip t
sliding sign in confirming proper endotracheal tube placement in neonates.
5 Page 5 of 9
Acknowledgments We thank all the nursing and medical staff of the Department of Emergency Medicine,
cr
ip t
Far Eastern Memorial Hospital, New Taipei City, Taiwan
us
Conflict of interest statement
an
The authors have no commercial associations or sources of support that might pose a
Ac ce p
te
d
M
conflict of interest.
6 Page 6 of 9
REFERENCES 1.
Kerrey BT, Geis GL, Quinn AM, et al. A prospective comparison of diaphragmatic
ultrasound and chest radiography to determine endotracheal
ip t
tube position in a pediatric emergency department. Pediatrics. 2009 Jun; 123(6): e1039-44
Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis
cr
2.
us
of neonatal pulmonary atelectasis using lung ultrasonography. Chest. 2015 Apr; 147(4): 1013-9.
Sim SS, Lien WC, Chou HC, et al. Ultrasonographic lung sliding sign in
an
3.
confirming proper endotracheal intubation during emergency intubation.
4
M
Resuscitation. 2012 Mar; 83(3): 307-12.
Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid
d
ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube
Ac ce p
te
depth in children. Resuscitation. 2015 Apr; 89: 8-12.
7 Page 7 of 9
Figure Legend Figure 1 Demonstration of lung sliding: (A) Dynamic lung sliding generated sandy pattern
ip t
over M-mode, generally called a seashore sign. (B) Longitudinal scan over midaxillary intercostal space, pleural lines (arrow), ribs (triangle).
cr
Demonstration of absence of lung sliding: (C) Absence of lung sliding produced succession of horizontal lines with intermittent fluctuation (round shape) with heart
us
beat over M-mode, this pattern is called the lung pulse. (D) Longitudinal scan over
an
mid-axillary intercostal space, pleural lines (arrow), ribs (triangle).
Demonstration of chest radiography: (E) the tip of endotracheal tube was deviated and
Ac ce p
te
d
M
located at the right main bronchus, indicating a right main-stem intubation.
8 Page 8 of 9
Page 9 of 9
ed
pt
Ac ce us
an
M
cr
ip t
S0300-9572(16)30137-X http://dx.doi.org/doi:10.1016/j.resuscitation.2016.06.030 RESUS 6841
To appear in:
Resuscitation
Received date: Accepted date:
21-6-2016 23-6-2016
Please cite this article as: Sim S-S, Sun J-T, Fan C-M, Tsai K-C, The utility of ultrasonography to confirm proper endotracheal tube placement in neonates, Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.06.030 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Letter to the Editor
The utility of ultrasonography to confirm proper endotracheal tube placement in
ip t
neonates
cr
Shyh-Shyong Sim*, MD, Jen-Tang Sun, MD, Chieh-Min Fan, MD, MSc, Kuang-
us
Chau Tsai, MD, MSc
an
Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan Correspondent author
M
*
nil
Financial support:
nil
Financial disclosure:
the authors have no connection to any companies or products
te
d
Conflict of interest:
Ac ce p
mentioned in the article
Word count:
494
words
Address for reprints:
Shyh-Shyong Sim, MD.
Department of Emergency Medicine, Far Eastern Memorial Hospital No.21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan Tel: 886-2- 8966-7000 Ext 1125 Email: [email protected] or [email protected]
1 Page 1 of 9
Correspondent author: Shyh-Shyong Sim, MD.
ip t
Department of Emergency Medicine, Far Eastern Memorial Hospital
Tel: 886-2- 8966-7000 Ext 1125
Ac ce p
te
d
M
an
us
Email: [email protected] or [email protected]
cr
No.21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan
2 Page 2 of 9
Letter to the Editor
The utility of ultrasonography to confirm proper endotracheal tube placement in
ip t
neonates
cr
Sir,
us
Using physical examination to confirm the endotracheal tube placement on a neonate
an
is never an easy task, especially in the chaotic resuscitation scenario. By our own experience, we proposed the usage of bedside ultrasonography to confirm proper
M
endotracheal tube placement in a timelier manner.
d
An obstetrician rushed in our emergency department around midnight, he’s holding a
te
newborn baby, giving mouth to nose and mouth ventilation to the baby. The baby was cyanotic and appeared flaccid. We took over the baby and put on a bag-valve-mask
Ac ce p
for positive ventilation. According to the obstetrician, the baby was just delivered, appearing apnea and cyanotic, he brought the baby to our emergency department immediately. Electrocardiogram showed the baby’s heart rate was around 50 bpm, we started chest compression immediately and prepared for endotracheal intubation. Since we had no specific body weight and body height of the newborn, we used Broselow Pediatric Emergency Tape to guide medication dosages and the size of equipment. We inserted a 3.0 endotracheal tube and fixed the tube at 10.5cm depth. Soon after the ventilation established, baby’s heart rate returned to 120 bpm with pulse. Baby’s cyanosis resolved but still remained pale. Pulse oximeter showed SpO2 90%. We
3 Page 3 of 9
checked bilateral breath sound and the expansion of chest wall to confirm the placement of endotracheal tube, there was no noticeable difference of both sides. Upon waiting for portable chest radiography to check the position of endotracheal
ip t
tube, we used a bedside ultrasonography to check lung sliding sign over bilateral midaxillary line. We found presence of lung sliding over right side (Fig.1A, B) but
cr
absence over left side (Fig.1C, D), there was presence of lung pulse over left side. The finding showed that there was adequate ventilation over right lung, indicating we
us
might do a right main-stem intubation. Soon after the portable chest radiograph taken,
an
we relocated endotracheal tube, and rechecked bilateral lung sliding sign, after confirming presence of bilateral lung sliding signs, we fixed the endotracheal tube at
M
8cm depth. Baby’s SpO2 became 100% and skin became pinkish. Later, the chest radiograph taken earlier, revealed the position of endotracheal tube, which was a right
d
main-stem intubation (Fig.1 E). The finding of chest radiography coincides with our
te
assessment through ultrasonography examination.
Ac ce p
This experience indicated that bedside ultrasonography is a feasible and timely tool for confirmation of proper endotracheal tube placement in neonates. Previous study compared diaphragmatic ultrasonography with chest radiography in determine endotracheal tube position in pediatrics, showing that diaphragmatic ultrasonography was not equivalent to chest radiography but was a timelier manner.1 Recent study
demonstrated the main ultrasound findings of neonatal pulmonary atelectasis is the absence of lung sliding and presence of lung pulse.2 Our previous study proposed the
usage of ultrasonography lung sliding signs in confirming proper endotracheal tube in adults.3 In addition, tracheal rapid ultrasound saline test is not applicable in neonates.4
4 Page 4 of 9
We strongly encourage further study to validate the usage of ultrasonography lung
Ac ce p
te
d
M
an
us
cr
ip t
sliding sign in confirming proper endotracheal tube placement in neonates.
5 Page 5 of 9
Acknowledgments We thank all the nursing and medical staff of the Department of Emergency Medicine,
cr
ip t
Far Eastern Memorial Hospital, New Taipei City, Taiwan
us
Conflict of interest statement
an
The authors have no commercial associations or sources of support that might pose a
Ac ce p
te
d
M
conflict of interest.
6 Page 6 of 9
REFERENCES 1.
Kerrey BT, Geis GL, Quinn AM, et al. A prospective comparison of diaphragmatic
ultrasound and chest radiography to determine endotracheal
ip t
tube position in a pediatric emergency department. Pediatrics. 2009 Jun; 123(6): e1039-44
Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis
cr
2.
us
of neonatal pulmonary atelectasis using lung ultrasonography. Chest. 2015 Apr; 147(4): 1013-9.
Sim SS, Lien WC, Chou HC, et al. Ultrasonographic lung sliding sign in
an
3.
confirming proper endotracheal intubation during emergency intubation.
4
M
Resuscitation. 2012 Mar; 83(3): 307-12.
Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid
d
ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube
Ac ce p
te
depth in children. Resuscitation. 2015 Apr; 89: 8-12.
7 Page 7 of 9
Figure Legend Figure 1 Demonstration of lung sliding: (A) Dynamic lung sliding generated sandy pattern
ip t
over M-mode, generally called a seashore sign. (B) Longitudinal scan over midaxillary intercostal space, pleural lines (arrow), ribs (triangle).
cr
Demonstration of absence of lung sliding: (C) Absence of lung sliding produced succession of horizontal lines with intermittent fluctuation (round shape) with heart
us
beat over M-mode, this pattern is called the lung pulse. (D) Longitudinal scan over
an
mid-axillary intercostal space, pleural lines (arrow), ribs (triangle).
Demonstration of chest radiography: (E) the tip of endotracheal tube was deviated and
Ac ce p
te
d
M
located at the right main bronchus, indicating a right main-stem intubation.
8 Page 8 of 9
Page 9 of 9
ed
pt
Ac ce us
an
M
cr
ip t