Life in the Fast Lane Medical Blog
Emergency Medicine education blog
aka Anaesthetic Addler 002
An ‘old school’ anaesthetist once asked at a conference:
“What single maneuver can you perform to absolutely confirm tracheal tube placement, that does not involve a device or monitor?”
What was his answer?
Leave a comment with your suggestions — we’ll provide an answer in an upcoming post…
Update: The answer has now been posted here!
About Minh Le CongMinh is the Medical Education Officer for RFDS Queensland, providing governance and coordination for teaching and training programs across the state, and is a Senior Lecturer in Aeromedical Retrieval at James Cook University.
[...] 2012 By Minh Le Cong Leave a Commentaka Anaesthetic Addler 002 (answer) Hi folks,Remember back to Feb 28th when gave you this puzzle to ponder…An ‘old school’ anaesthetist once asked at a [...]
Do a direct laryngoscopy and actually look to see that the tube is in between the cords…unless you count the laryngoscope as a “device”
If I had to confirm placement of ETT without device or monitor, I would (VERY RELUCTANTLY) suck firmly on the tube and hope I got nothing back but air. Then I would be happy for two reasons. 1. confirmed placement and 2. no vomit in mouth.
Almost as bad,….. I have a friend anaesthetist who once famously had to give “mouth to tube” breaths in an emergency situation when no other equipment was available. Quick thinking and life saving but most unpleasant…..
I have had patients with vomit in their airways before I arrived, why would I want to turn the tube into a mutant version of a DeLee Suction Catheter?
what if the belly does not return anything?
How reliable is sucking on a tube placed in the esophagus at identifying esophageal placement?
What negative pressure must be produced to bring up stomach contents?
How can I be certain that what returns is from the stomach and not some juicy lung butter from a pneumonia patient?
I like the creativity of the suggestion, but I doubt the reliability of the results.
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Unless a 50ml catheter tip syringe is a device, you could do what’s referred to as a “Wee test” (apologies if spelled incorrectly). Put the syringe on the end of the ETT and withdraw quickly. If the trachea is intubated, no resistance should be felt due to its rigidity and holding shape. If the ETT is in the oesophagus then theoretically there should be resistance felt as negative pressure from pulling back the syringe collapses the oesophagus. In the case of not ‘seeing’ the tube go through the cords and having no monitoring, this may be the answer?
I’ve seen this done, but it feels overly fussy. See Dr D, Duncan, and JB below for classical, reliable technique.
Seeing the ETT go through the cords during laryngoscopy.
Agreed, however I feel there is something else we are both missing…
Seeing the ETT go through the cords during laryngoscopy is strongly associated with a misplaced tube.
Misplaced tubes are left in place because the person thought that what they saw was the tube going through the cords.
We know too much about optical illusions to fall for the delusion of I saw the tube go through the cords.
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You guys are all using devices!!
Suck on the tube.
It’s the only way to be sure….
Whilst sucking on the tube is an inspired touch, it is not fool proof technique of confirmation of tracheal placement. This maneuver. does not require doing anything more than what you would usually do after intubation..well perhaps a little more ..but it does not involve using a laryngoscope.
These old timer anaesthetists are a wise bunch..out of necessity..no fancy toys to rely on!
Easy. Take it out…if they desaturate and die, then you know the tube WAS in the right place.
Might not help the patient, but it answers the question and is device free.
This is like one of those oldtime puzzles -- if one guard always lies and the other always tells the truth, what question should I ask to exit the maze?
funny, maybe they should have added without killing the patient in the question….funny though!
This would be confirmation if not for the problem of intubated patients developing complications, desaturating, and dying.
Intubated patients frequently die.
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Shove it all the way in. If you meet resistance, you’re in the airway. If the tube disappears down the throat, it’s gone to the stomach.
‘sgotta be this one eh?
Anterior neck dissection and removal of the anterior trachea. If you can visualise the ETT within the trachea then that would be pretty reliable.
Push it in down RMB and confirm unilateral chest rise / reduction in Vt / physical block to further ETT insertion.
Wake up the patient, hold his nose, close his lips around ETT and see if he can breathe through it.
Old school anaesthetists aside, I think the fact that the literature suggests there is no definitive single test means that whatever dogma he might tout is if limited real-work utility.
I agree.
With any spontaneously breathing intubated patient, I remove the bag, put my thumb over the end of the tube to prevent air movement, and find that the sudden inability of the previously spontaneously breathing patient to move air, in spite of make effort to move air, followed by resolution of this inability to move air as soon as I release the end of the tube is a pretty good confirmation. Only one attempted breath should be required -- much less apnea than most intubation attempts.
Of course, nothing is perfect at identifying placement. A group of tests is best.
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The trachea is anterior to the esophagus. Palpate the space right above the sternal notch, if the tube is in the trachea you should feel the tube’s cuff in that location.
I’m with Duncan and JB… perfect, classical, reliable technique.
Smell the tube?
Do they stick their hand in and feel tube position with their fingers?
My thoughts also immediately went to sucking the tube. Then I started thinking about how specific a small vomit-back sign would be for oesophageal intubation in the setting of someone found down (we are ED after all) who had already aspirated. Placement could still be tracheal. Then I reflected on the tragedy that could unfold, both patient and enthusiastic intubator aspirating on the same piece of vomit. We suffer enough in our job. Bring on the answer!
So my old veterinary medicine experience may come in handy after all. Three things:
1. Mirror or glasses at end of ETT and see if it fogs with patients ventilation, clearly if there is no air movement through the tube there will be no fogging of the glass on expiration by the patient.
2. With cats/dogs we used to pluck a few hairs off and hold over the end of the tube -- the hairs move up and down with the patients ventilation. If the tube was not in the trachea then no movement. Of course you could use a few fibres from cotton wool as well.
3. If absolutely NOTHING else is allowed other than our own senses, then put your ear right up to the end of the tube -- it is amazing but you can feel & hear the movement of air with breathing against our incredibly sensitive ear canals.
Feel the neck; if you feel TWO hard tubes it’s down the wrong hole.
Of course I just realised my earlier post is relying on the fact that the patient is spontaneously breathing.
If not, dont suck but BLOW down the tube. If in trachea chest will rise appropriately. If in in oesophagus chest will not rise (possibly some abdominal movement as stomach inflates).
Post mortem?
I suspect that the answer is along the lines of pulling out.
Hi folks
Someone has already posted the correct answer. guess who and what?
Final answer post to come soonish
It’s got to be JB’s suggestion. Best and simplest way to know for sure that you in the right place, and it even helps with depth -- With one finger pressing over the suprasternal notch you should be able to feel the cuff bounce in the trachea when you squeeze the external pilot balloon with your other hand.
There is no single fool proof confirmatory test to confirm placement despite the strong belief of old anesthesiologists.
I agree with Duncan: “Push it in down RMB and confirm unilateral chest rise / reduction in Vt / physical block to further ETT insertion.”
Same way you can confirm a bougie is in the right place if you can’t be sure you are feeling bumps from the rings…
Tube fogging with expiration?
30 years ago between undergrad at Balliol/Oxford and a US medical school I became one of the first “paramedics” in the country. It was a very clinical program (unlike most today -- just too expensive) run by a large city health department. We were expected to manage patients almost completely before an ambulance transported. I found then, and still today, to stick with a large and straight blade, use an “old time” tube with solid walls and what now would be a high pressure bulb. Then position pt., in, visualize -- the flash is nice -- and intubate; if in doubt early, force the tube down firmly and if resistance, your in. Unless there was a huge amount of aspirate or blood, deal with it later. Classic practice is to bag the pt. once while listening for breath sounds. If in doubt, some will show belly distention right away; with others take a second bag sounding over the belly. Today I’m a trauma surgeon in a camp that happens to house a early receiving hospital… 12 sand-bagged tents with one old portable xray and a CT Scanner. Battlefield trauma is nothing like you see even in civilian trauma centers. Pts. are usually tubed before they reach us but not always, and the thoracic injuries often require some sort of make-do surgical airway and tube. I’m still amazed at our save-rate given the incredible injuries we see. The service men and women are wonderful -- caring for them is a joy I would not miss for anything. Cheers form Sunny Afghanistan !!
Sounds like you should do a ‘postcard’ blog post!
Doc HUGO, you must write a postcard from the edge article for LITFL!
In fact I won’t release the answer post for this clinical challenge until you promise to do so!
I’ll contact Doc HUGO so he knows where to send the postcard…
Chris
I suppose patient survival is a goal? Otherwise you could pour water down the tube and see if the patient drowns…
You can try digital intubation and feel where the tube is. No device or monitor, just your figures.
No answer yet?
i’ve seen one of my icu bosses do something similar. he pressed over the anterior trachea (above the sternal notch where the ETT cuff should lie) whilst feeling the pilot balloon (for changes in volume due to transmitted pressure from pressing on the cuff which travels back up the pilot tube to the balloon).
don’t know if this is a ‘definitive method’ of confirming ETT placement but i thought it was a nifty trick…
tracheotomy?
Autopsy?
Put a bougie down and feel it arrest