American Journal of Emergency Medicine xxx (2016) xxxxxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Tracheal ultrasonography and ultrasonographic lung sliding for

conrming endotracheal tube placement: Faster? Reliable?
Sinan Karacabey a,, Erkman Sanr, MD b, Emin Gokhan Gencer, MD c, Ozlem Guneysel c
a
b
c

Bozok University Faculty of Medicine EM Dept, Yozgat, Turkey

Sultanbeyli State Hospital EM Dept, Istanbul, Turkey
Kartal Dr Lut Krdar Training and Research Hospital EM Dept, Istanbul, Turkey

a r t i c l e

i n f o

Article history:
Received 4 November 2015
Received in revised form 20 January 2016
Accepted 20 January 2016
Available online xxxx

a b s t r a c t
Background: In this study we aimed to evaluate the success of ultrasonography (USG) for conrming the
tube placement and timeliness by tracheal USG and ultrasonographic lung sliding in resuscitation and rapid
sequence intubation.
Materials and methods: This study was a prospective, single-center, observational study conducted in the
emergency department of a tertiary care hospital. Patients were prospectively enrolled in the study. Patients
who went under emergency intubation because of respiratory failure, cardiac arrest or severe trauma included
in the study. Patients with severe neck trauma, neck tumors, history of neck operation or tracheotomy and
under 18 years old were excluded from the study.
Results: A total of 115 patients included in the study. The mean age was 67.2 17.1 with age 1695 years old.
Among 115 patients 30 were cardiac arrest patients other 85 patients were non-cardiac arrest patients intubated
with rapid sequence intubation. The overall accuracy of the ultrasonography was 97.18% (95% CI, 90.1999.66%),
and the value of kappa was 0.869 (95% CI, 0.770.96), indicating a high degree of agreement between the
ultrasonography and capnography. The ulrasonography took signicantly less time than capnography in total.
Discussion: Ultrasonography achieved high sensitivity and specicity for conrming tube placement and results
faster than end-tidal carbon dioxide. Ultrasonography is a good alternative for conrming the endotracheal tube
placement. Future studies should examine the use of ultrasonography as a method for real-time assessment of
endotracheal tube placement by emergency physicians with only basic ultrasonographic training.
2016 Elsevier Inc. All rights reserved.

1. Introduction
Intubation is a challenging procedure in emergency departments
(EDs) because of the uncontrolled nature of the environment and a
lack of team preparedness and may lead to the development of
complications, such as unrecognized esophageal intubation [1], which
can cause high rates of mortality and morbidity.
Many techniques have been described for the conrmation of endotracheal tube placement [2], although chest radiography is considered
the most reliable method. In general, chest auscultation is used
for conrming tube placement, but unfortunately, 55% of one-lung
intubations are misdiagnosed by auscultation [3]. The 2010 American
Heart Association Cardiopulmonary Resuscitation Guidelines state that
quantitative waveform capnography is the gold standard method for
conrming tube placement [4], but this method has some limitations,

particularly in cardiac arrest patients, such as the need for epinephrine

use, low pulmonary ow and low cardiac output [5].
Ultrasonography (USG) has a wide range of uses in EDs. It is noninvasive, occurs in real time and thus improves the condence of the
physician in determining tube placement [6]. Tracheal ultrasonography
images are not affected by very low pulmonary ow, contrary to
capnography, and ultrasonographic detection of esophageal intubation
can be performed prior to ventilation of the patient. Earlier detection
of esophageal intubation could prevent ventilation of the stomach and
its associated complications, namely emesis and aspiration.
In this study, we aimed to evaluate the success of USG for conrming
tube placement and to evaluate the timeliness involved in tracheal USG
and ultrasonographic lung sliding for patients undergoing resuscitation
or rapid sequence intubation.
2. Materials and methods

Corresponding author at: Bozok Universitesi Aratrma ve Uygulama Hastanesi Adnan

Menderes Bulvar No:44, Yozgat, 66200.
E-mail addresses: karacabeysinan@yahoo.com (S. Karacabey), Erkman00@gmail.com
(E. Sanr), dr.gokhangencer@gmail.com (E.G. Gencer), guneysel@gmail.com (O. Guneysel).

This study was a prospective, single-center, observational study

conducted in the ED of a tertiary care hospital. The study was conducted
between September 1, 2013, and September 1st, 2014, and was approved
by the hospital ethics committee.

http://dx.doi.org/10.1016/j.ajem.2016.01.027
0735-6757/ 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Karacabey S, et al, Tracheal ultrasonography and ultrasonographic lung sliding for conrming endotracheal tube
placement: Faster? Reliable?, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.01.027

S. Karacabey et al. / American Journal of Emergency Medicine xxx (2016) xxxxxx

Fig. 1. (A) Demonstration of transducer placement just superior to the suprasternal notch. (B) Ultrasonographic image of esophageal intubation (C) Ultrasonographic image of tracheal
intubation. (D) Longitudinal scan over an intercostal space, pleural lines, Dynamic lung sliding generated sandy pattern over M-mode, generally called a seashore sign.

a second airway (double-tract sign), appeared after the transducer was

placed on both sides of the chest in the mid-axillary line near the fourth
to fth intercostal space (Fig. 1). The sonographers were not involved in
the patients' care and not aware of the waveform capnography results.
One emergency medical technician measured the durations from
completion of the endotracheal tube insertion to the time when
sonographer had interpreted the sonographic results and to the time
at which the capnography results were obtained.
A data collection form was created to record the patients' age,
gender, capnography results, USG results and elapsed time prior to
tube placement conrmation.

Patients were prospectively enrolled in the study. In particular,

patients who underwent emergency intubation due to respiratory
failure, cardiac arrest or severe trauma were included in the study.
In contrast, patients with severe neck trauma, neck tumors, history
of neck operation or tracheotomy, and under 18 years of age were
excluded from the study.
The patients enrolled in the study were separated into 2 groups: The
rst group consisted of cardiac arrest patients who underwent emergency intubation during cardiopulmonary resuscitation (CPR), and the
second group consisted of non-cardiac arrest patients who received
rapid sequence intubation (RSI).
Emergency intubations were performed by rst-year emergency
medicine residents. Tracheal and lung sliding USG were performed concurrently with intubation by 2 emergency medicine specialists who had
completed a USG training course developed by the Emergency Medicine
Physicians Association of Turkey.
Post-intubation conrmation of endotracheal tube placement was
performed using a capnometer (EMMA Mainstream Capnometer).
A Toshiba Aplio500 USG device and a 7.5 mHz linear probe were
used for USG. The transducer was placed transversely on the anterior
neck just above the suprasternal notch. The position of the trachea
was demonstrated by the appearance of a comet-tail artifact,
specically a hyperechoic air-mucosa (A-M) interface with a posterior
reverberation artifact. To identify bilateral lung sliding over the lungs
after intubation, the identied endotracheal tube position was dened
as endotracheal if only one A-M interface with a comet-tail artifact
was observed or intraesophageal if a second A-M interface, mimicking

2.1. Statistical analysis

Various test characteristics, including sensitivity, specicity, positive
predictive value (PPV), negative predictive value (NPV) and positive
and negative likelihood ratios, were calculated using standard formulas
for a binominal proportion, and the corresponding 95% condence
intervals (CIs) were calculated using the Wilson interval method. All
statistical analyses were performed using SPSS statistical software,
version 18.0 (SPSS Inc, Chicago, IL, USA) and SAS system ver. 8.2 (SAS Institute
Inc, Cary, NC, USA). P b .05 was considered statistically signicant.
3. Results
A total of 115 patients were included between September 1st, 2013
and September 1st, 2014. The patient ages ranged from 16 to 95 with a

Table 1
Ultrasonographic detection of tracheal or esophageal intubation

USG tracheal
USG esophageal

Total

RSI

Cardiac arrest

n = 115

n = 85

n = 30

Tracheal

Esophageal

Tracheal

Esophageal

Tracheal

Esophageal

69
2

5
39

56
0

0
29

13
2

5
10

USG, Ultrasonography; RSI, Rapid Sequence Intubation.

Please cite this article as: Karacabey S, et al, Tracheal ultrasonography and ultrasonographic lung sliding for conrming endotracheal tube
placement: Faster? Reliable?, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.01.027

S. Karacabey et al. / American Journal of Emergency Medicine xxx (2016) xxxxxx

Table 2
Test characteristics of the USG for tube placement conrmation

Sensitivity,% (95% CI)

Specicity, % (95% CI)
PPV, % (95% CI)
NPV, % (95% CI)

Total

RSI

Cardiac arrest patients

97,18 (90,19-99.66)
88,64 (75,44-96,21)
93,24 (84,93-97,77)
95,12 (83,47-99,4)

100 (93,62-100)
100 (88.06-100)
100 (93,62-100)
100 (88,06-100)

86,67 (59,54-98,34)
66,67(38,38-88,18)
72,22 (46,52-90,31)
83,33 (51,59-97,91)

PPV, positive predictive value; NPV, negative predictive value; CI, condence interval.

mean of 67.2 17.1. Among the 115 patients, 30 were cardiac arrest patients, and the remaining 85 patients were non-cardiac arrest patients
subjected to rapid sequence intubation.
The results of tracheal and esophageal intubation are shown in
Table 1. The sensitivity, specicity, PPV and NPV of the tracheal ultrasound and ultrasonographic lung sliding sign, which were determined
using capnography as the gold standard, are shown in Table 2.
The diagnostic accuracy of ultrasound for conrming endotracheal
tube placement was found to be superior for patients subjected to
rapid sequence intubation compared with the cardiac arrest patients,
but there was no signicant difference between the two groups.
Forty-four esophageal intubations were performed, including 29
in noncardiac arrest patients and 15 in cardiac arrest patients. The
overall ultrasonography accuracy was 97.18% (95% CI, 90.1999.66%),
and the value was 0.869 (95% CI, 0.77-0.96), indicating a high degree
of agreement between the ultrasonography and capnography results.
The positive likelihood ratio was 8.55, and the negative likelihood
ratio was 0.03. No signicant differences were found between the
non-cardiac arrest and cardiac arrest groups.
The operating time of tracheal ultrasound is shown in Table 3,
and the total duration of ultrasonography was signicantly less than
that of capnography.
4. Discussion
This study aimed to evaluate the accuracy and decision time of tracheal and lung sliding USG for conrming tube placement in both the
RSI and CPR groups. Tracheal ultrasound achieved high sensitivity and
specicity for conrming tube placement and yielded results faster
than end tidal CO2. For this reason, USG may be a good choice for
conrming tube placement.
Proper endotracheal intubation means that the tip of the endotracheal tube is located in the trachea and does not advance beyond the carina and into a bronchus. Although quantitative waveform capnography
is recommended by the American Heart Association in its 2010
Cardiopulmonary Resuscitation Guidelines as the gold standard method
for conrming tube placement, it has some limitations, particularly in
cardiac arrest patients, such as the need for epinephrine, low pulmonary
ow and low cardiac output [4,5].
Ultrasound is a common tool in EDs. In fact, ultrasound has many
uses in an ED, including the conrmation of endotracheal tube
placement [7,8]. Previous studies have described the high sensitivity
and specicity of the ultrasonographic lung sliding sign for conrming
endotracheal tube placement. Lung sliding has been shown to be highly
sensitive for differentiating esophageal versus tracheal intubation and
shows one-lung intubation correctly; however, this method requires

Table 3
Time Requirement for tube place conrmation

ETCO2
USG

Mean

SD

Levene's
test F
statistics

Levene's test
probability

t Statistics

t Probability

11.7565
5.8087

3.0452
3.2630

2.430

0.120

14.291

0.000

ETCO2, end-tidal CO2.

ventilation to detect the results and is time-consuming [911].

In other studies, promising results have been obtained with tracheal
ultrasound for endotracheal tube placement conrmation. Ma et al
used transcricothyroid ultrasound to conrm tracheal intubation in a
cadaveric model and demonstrated high sensitivity and specicity.
Using tracheal ultrasonography, we can assess tracheal intubation in
real time, and there is no need to ventilate the patients, but one-lung intubation may be misdiagnosed. As a result, in our study, we combined
two techniques for conrming tube placement [12]. Two prospective
studies showed that tracheal ultrasound presented up to 100% sensitivity and specicity in live humans under a well-controlled operatingroom setting [13,14]. In a recent study performed on 30 ED patients,
high sensitivity and specicity values were obtained using combined
ultrasonographic methods [15]. However, these studies have several
limitations. First, these studies were performed on cadaveric models
or on patients in well-monitored operating rooms, making their results
less applicable to emergency intubation. In addition, most of the studies
had small sample sizes, indicating that their statistical power may
be inadequate.
Our results demonstrated another potential use of ultrasound during
resuscitation. The Advanced Cardiac Life Support guidelines emphasize
early chest compressions and minimal interruptions. Tracheal USG
can be performed in synchrony with endotracheal tube placement,
even before clinical auscultation and without interruption of chest
compressions [4].
Ultrasonography of the endotracheal tube placement at the trachea
in already intubated patients has been described by Drescher et al
[16], who reported that esophageal intubation appears as an anechoic
circle close to the trachea as the tube enters the esophagus.
In our study, we had a high rate of esophageal intubation (38%) because the intubations were performed by inexperienced rst-year
emergency medicine residents. Thus, we found that ultrasonography
provides a faster diagnosis of false intubations.
Based on the results of study, we learned that the combination of
tracheal USG and lung sliding is superior to capnography. In addition,
in cardiac arrest patients, this combination is better than capnography
because USG is not affected by low pulmonary ow. Furthermore,
we demonstrated the considerable time advantage of ultrasound
over capnography in conrming proper endotracheal intubation.
However, USG was also affected by CPR, and the success rates in these
patients were decreased compared with the success rates of those
undergoing RSI.
In conclusion, ultrasonography is a good alternative for conrming
endotracheal tube placement. Future studies should examine the use
of ultrasonography as a method for the real-time assessment of
endotracheal tube placement by emergency physicians with only basic
ultrasonographic training. The impact of the use of this technique on
the laryngeal view and the feasibility of using this technique in the ED,
intensive care units and out-of-hospital settings should be evaluated
with a wider range of patients.

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placement: Faster? Reliable?, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.01.027

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Please cite this article as: Karacabey S, et al, Tracheal ultrasonography and ultrasonographic lung sliding for conrming endotracheal tube
placement: Faster? Reliable?, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.01.027