(1070) Handheld Ultrasound Confirmation of Pediatric Endotracheal Tube Placement in a Low-Resource Country

Introduction: Rapid confirmation of endotracheal tube (ETT) placement is crucial in critically ill children. While chest X-ray (CXR) is standard of care, particularly in resource limited countries, it is a radiation hazard, expensive, and requires specialized resources. Alternatively cited “gold standard” verifications, such as waveform or colorimetric capnography, may be costly for clinicians in developing countries to have access to. Airway ultrasound (AUS) is considered a low cost, reliable, fast, and noninvasive alternative. We, therefore, aim to study the accuracy of bedside AUS as compared to CXR, using an ultraportable handheld device, for confirmation of ETT placement in neonatal and pediatric intensive care units in Nepal.

Methods: A prospective, observational study was conducted between October 2023 to April 2024 of children, newborn to 15 years old. AUS was performed by handheld device after ETT placement and prior to CXR imaging. Patients without informed consent were excluded. Transverse tracheal view was obtained to confirm tracheal or esophageal intubation, and sagittal second intercostal and diaphragmatic views to exclude endobronchial intubation. Sensitivity and specificity were calculated for accuracy.

Results: AUS was performed on 59 children, 37 (63%) were females. Median age of newborns (n=27) was 3 days (IQR 1, 3) and children (n=32) 24 months (IQR 12, 84). AUS demonstrated tracheal placement of ETT in 53 (89.8%) children; among whom 3 were initially noted to be esophageal intubations by AUS, subsequently reintubated and confirmed to be correctly placed by both AUS and CXR. Four were endobronchial and 2 uninterpretable by AUS. CXR agreed with AUS on all 53 patients with correct placement. There were 3 more correct tracheal placement and 3 endobronchial intubations on CXR. Sensitivity and specificity of AUS for detection of ETT placement in the trachea, compared with CXR, were 94.6% (95% CI 85.1 to 98.9), and 100% (95% CI 29.2 to 100), respectively. Accuracy was calculated at 94.9%.

Conclusions: Our study demonstrated good accuracy of AUS using ultraportable, handheld device to confirm ETT placement in neonates and children. Since the device is affordable and easy to learn, it could be a reliable and effective method to confirm ETT placement in a resource limited country like Nepal.