Portal de Periódicos da CAPES

Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant

2012; Elsevier BV; Volume: 83; Issue: 6 Linguagem: Inglês

10.1016/j.resuscitation.2012.02.014

1873-1570

Ignacio Oulego‐Erroz, Paula Alonso‐Quintela, Silvia Rodríguez‐Blanco, D. Mata Zubillaga, María Fernández Miaja,

Respiratory Support and Mechanisms

Endotracheal tube (ET) verification in newborns is usually achieved primarily by direct visualization of the ET passing through the vocal cords by direct laryngoscopy. This is the preferred method by most experienced neonatologists. However, there is evidence indicating that incidental oesophageal intubation is frequent leading to potential serious harm for the baby so a secondary verification method may be necessary.1O'Donnell C.P. Kamlin C.O. Davis P.G. et al.Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects.Pediatrics. 2006; 117: 16-21Crossref Scopus (262) Google Scholar As clinical signs such as auscultation alone may be inaccurate in the preterm, an end tidal carbon dioxide (ETCO2) detector is usually recommended. However, in the setting of low or absent pulmonary blood flow such as during resuscitation or severe hypotension capnography may yield false negative results.2Kamlin C.O. O'Donnell C.P. Davis P.G. et al.Colorimetric end-tidal carbon dioxide detectors in the delivery room: strengths and limitations. A case report.J Pediatr. 2005; 147: 547-548Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Ultrasound is an alternative and complementary method for ET verification shown to be at least as rapid and accurate as capnography for emergent intubation in children and adults.3Galicinao J. Bush A.J. Godambe S.A. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: a feasibility study.Pediatrics. 2007; 120: 1297-1303Crossref PubMed Scopus (85) Google Scholar, 4Pfeiffer P. Rudolph S.S. Børglum J. et al.Temporal comparison of ultrasound vs. auscultation and capnography in verification of endotracheal tube placement.Acta Anaesthesiol Scand. 2011; 55: 1190-1195Crossref PubMed Scopus (39) Google Scholar Here we communicate its use in a very low birth weight preterm infant and illustrate the technique. A 31 week gestation and 1.410 g 5-days old female baby was being treated for severe sepsis and necrotizing enterocolitis in our NICU. He was on high ventilatory support (Peak pressure 27 mmHg, PEEP 7 mmHg, FiO2 60%) because of respiratory failure needing surfactant replacement. He suffered an accidental extubation with rapid loss of lung recruitment, severe desaturation (Sat 70%), bradycardia and hypotension that did not respond to bag mask ventilation. She was reintubated with a 2.5 mm uncuffed tube without improvement (Sat 75%). Capnography was not readily available and we decided to check ET location by ultrasound. We used an 8-Hz microconvex transducer in the longitudinal and transversal plane above the suprasternal notch. We were able to clearly see the ET within the trachea immediately posterior to tracheal anterior rings (Fig. 1). We then added a PEEP valve to the bag and ventilated the baby with an increasing level of PEEP (max. 8 mmHg) oxygen saturation slowly raised in two minutes and the baby stabilized. Ultrasound may be useful to verify ET during emergent intubation of preterm babies. The most important technical issue is the use of a small sized transducer suitable for the preterm's neck. A sectorial or microconvex high frequency transducer may be optimal. Transducer should be placed 1–2 cm above the suprasternal notch (cricotiroid membrane) in the longitudinal and transversal planes. Longitudinal plane may be more useful as we can see echogenic anterior tracheal rings with the ET lying just beneath them as two echogenic lines. With minimal caudal angulation of the transducer toward the suprasternal notch we may be able to identify the ET tip (Fig. 1). Ultrasound is an alternative and adjunct method to verify ET that in neither case substitutes direct laryngoscopy or careful clinical assessment. It may be especially useful during resuscitation or low pulmonary flow situations where capnography is less reliable.5Chou H.C. Tseng W.P. Wang C.H. et al.Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation.Resuscitation. 2011; 82: 1279-1284Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar Another potential advantage is that, compared to direct laryngoscopy, ultrasound permits to verify ET position without interrupting ventilation or chest compressions and with less risk of accidental extubation. The authors have no conflict of interest to declare.