Radiological validation of endotracheal tube insertion depth in prehospital emergency patients

DM Maybauer, MO Maybauer, H Wolff, E Pfenninger, W Geisser
2009 Critical Care  
Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician
more » ... uation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours. Introduction Endotracheal intubation (ETI) engages the patient's life and demands a good experience. A preliminary prospective study has shown in one hospital that emergency physicians (EPs) rarely performed ETI. Do the EPs in Ile de France (Paris region) have sufficient experience and regular training to realise this procedure safely in the emergency room (ER)? Methods We conducted a descriptive telephone-based questionnaire study to assess EPs' endotracheal intubation skills through all ERs in Ile de France public hospitals. A questionnaire was completed by the investigator during a 10-minute telephone call with at least one EP in each ER. The structure of hospitals, number of ETIs performed, devices and personnel available and the existence of protocols were collected. Their usual practice of sedation and intubation, training and proposals for changes were noted. Results The study was made through all of the 64 public hospitals of Ile de France. Fifty-six hospitals have an ICU, 37 a mobile ICU. We questioned 96 EPs; that is, 10% of EPs from our region. All of the 96 EPs called responded. These physicians were certified emergency physicians (CAMU) for 90% of them. The median of ETI declared was 24.5/year per ER. Thirty-eight percent of EPs performed less than five ETIs during the past 2 years. The success rate reported was 85%. In 94% of ERs, metallic blades and Eischmann mandrin were available and about two nurses can help during the procedure. Predictive criteria for difficult ETI cited the most were: short neck, obesity, small mouth opening and otorhinolaryngology disease or previous history of cervical radiotherapy. Seventy-six percent of EPs followed the recommendations for preoxygenation and 91% performed rapid sequence induction. The vast majority (76%) of ERs did not have standardized procedures for airway management. Theoretical training was acquired for 46% of EPs by the CAMU, practical training occurring in the operating room for 71%. Among the EPs interviewed, 87% believe that they should remain the principal actor for ETI -although as high as 89% of them consider that they were insufficiently trained in ETI management and only 41% pursued continuing medical education on that theme. Seventyseven percent proposed to spend time in the operating room to improve their practice of ETI. Conclusions ETI is rarely performed in the ER. It should be part of the EP curricula and written procedures should be made. Introduction Incorrect positioning of the endotracheal tube (ETT) within the airway after emergent intubation can result in serious complications. Accidental mainstem bronchus intubation is associated with contralateral atelectasis, tension pneumothorax, hypotension, and decreased survival. Conversely, failure to place the tube several centimeters beyond the vocal cords may result in inadvertent extubation, aspiration, pneumonia, or laryngeal spasm [1]. The aim of this study was to investigate the occurrence of ETT malpositioning after emergency intubation in the out-of-hospital setting. Methods A retrospective study of a 5-year time period, using records of 1,081 patients admitted to the trauma emergency room (ER) at a university hospital. Within 30 minutes after admission, a chest X-ray or whole-body CT scan was routinely performed in intubated patients to determine the tube-tip-carina relationship. Results Sixteen out of 1,081 patients died immediately after admission to the trauma ER and were not further radiologically diagnosed. Of the surviving 1,065 patients, 346 (32.5%) were female and 719 (67.5%) male. In the group of 488 intubated patients, 346 (70.9%) were correctly intubated, 89 (18.2%) were not correctly intubated -herein were 64 patients (14.7%) intubated with tip-carina distance <2 cm, and 25 patients (5.7%) were endobronchially intubated. Chest X-ray scans were not available for 53 patients (10.9%). Detailed data on ETT placement were available in 435 patients; 346 (79.5%) with correct ETT placement, 89 (20.5%) with incorrect ETT placement. None of the patients displayed an esophageal or pharyngeal intubation (0%). Of 435 patients, 324 had been intubated preclinically on scene -254 (78.4%) were correctly intubated, 70 (21.6%) were not correctly intubated. Conclusions This study clearly shows that ETT misplacement in emergency patients is still a serious problem with an incidence of 21.6% in our study, of which 5.7% were endobronchially intubated. We conclude that the skill level of the operator may be key in determining efficacy of endotracheal intubation. Based on our findings, all efforts should be made to verify the tube position with immediate radiographic confirmation after admission to the ER. Critical Care 2009, 13(Suppl 1):P5 (doi: 10.1186/cc7169) S3 Available online http://ccforum.com/supplements/13/S1 usual way, at a random phase of the ventilator cycle. For the synchronized film, the investigator wore a lead apron and dosimeter, stood 1 to 1.5 meters away from the patient, and pressed the inspiratory hold button. The sequence of the paired films was computer-randomized. The ventilator model, settings, patient position and portable X-ray machine settings were kept constant between films. Patients served as their own controls. Films were independently scored (1 = not clear/poorly inflated, 5 = very clear/well inflated) by two specialist radiologists based on five criteria: (i) clarity of lines and tubes, (ii) definition of pulmonary vasculature, (iii) visibility of mediastinum, (iv) definition of the diaphragm and (v) degree of lung inflation. Linear regression, taking two radiologists' scores of each patient into account, was used to examine whether there were any differences in the criteria ratings between random and synchronized films. Radiologists and statistician were blinded. Results We recruited 110 patients; there were no complications from the breath-hold maneuver. Dosimeter readings were negligible. Synchronized films had higher total scores and mean scores for criteria (ii) to (v), 95% confidence interval. P values were statistically significant: for total score, P <0.001; and for criteria (ii), P = 0.001; (iii), P <0.001; (iv), P <0.01; and (v), P <0.001. Conclusions Synchronizing the CXR to end-inspiration improves the quality of the film and is safe. Reference 1. Langevin PB, Hellein V, Harms SM, Tharp WK, Cheung-Seekit C, Lampotang S: Synchronization of radiograph film exposure with the inspiratory pause. Effect on the appearance of bedside chest radiographs in mechanically ventilated patients.
doi:10.1186/cc7167 pmcid:PMC4083889 fatcat:xtl3on2vkffynchxl6odvwla6y