Point-of-Care Ultrasound for Intubation Confirmation of COVID-19 Patients

The novel coronavirus disease of 2019 (COVID-19) is associated with significant morbidity and mortality, as well as large numbers of patients requiring endotracheal intubation. While much of the literature has focused on the intubation technique, there is scant discussion of intubation confirmation. Herein, we discuss the limitations of traditional confirmatory approaches, summarize the literature supporting a role for point-of-care ultrasound in this application, and propose an algorithm for intubation confirmation among COVID-19 patients.


Gottlieb et al.
POCUS for Intubation Confirnation of COVID-19 Patients that auscultation alone may misidentify mainstem intubation in 35-60% of patients. [15][16][17] While radiographs are typically the gold standard for assessing ETT depth, they can be significantly delayed due to the PPE necessary to perform this task and limited departmental resources, which may lead to significant lung barotrauma for unrecognized mainstem intubations in this population with limited oxygen reserve.

ROLE OF POINT-OF-CARE ULTRASOUND FOR INTUBATION CONFIRMATION
POCUS has been increasingly recognized as a valuable tool for intubation confirmation. One approach for this is the transtracheal technique, wherein a clinician places the transducer across the patient's neck post-intubation to visualize the ETT within the trachea or esophagus. This can be facilitated by gently twisting the ETT to create a motion artifact. 18,19 A recent systematic review and meta-analysis found that transtracheal ultrasound was 99% sensitive and 97% specific for confirming ETT location among adult patients. 20 A similar review among pediatric patients found that POCUS was 92-100% sensitive and 100% specific. 21 Studies have also demonstrated that the accuracy remains consistent regardless of ETT size or transducer type. 22,23 Additionally, the learning curve for identifying ETT placement with transtracheal POCUS has been suggested to be relatively short. 24 Importantly, this modality offers the unique benefit that it does not require positive pressure ventilation, thereby minimizing additional exposure to staff.
Other studies have suggested using indirect signs, such as bilateral lung sliding or diaphragmatic elevation for intubation confirmation with a high degree of accuracy. 25 Two studies demonstrated that the combination of lung sliding with transtracheal POCUS further increased the diagnostic accuracy over either in isolation. 26,27

ROLE OF POINT-OF-CARE ULTRASOUND FOR DETECTING MAINSTEM INTUBATION
Mainstem intubation can be detected through the following three sonographic assessments: lung sliding; diaphragmatic excursion; or the presence of lung pulse. In a mainstem intubation there is no air flow through the contralateral lung, resulting in the absence of the lung sliding (ie, motion artifact visualized between the visceral and parietal layers of the pleura) on that side. Studies of both cadaveric models and emergency department patients have demonstrated that unilateral right lung sliding was 69-92% sensitive and 55.6-100% specific for detecting right mainstem intubation. 28,29 When compared with auscultation, this technique has outperformed auscultation in both adult and pediatric patients. 30,31 Sonographic assessment of hemidiaphragmatic movement can also be used as a surrogate for ventilation of that lung. When a lung is ventilated by air, the diaphragm will move inferiorly, allowing for direct visualization of lung expansion. Studies have found that this technique is 91-100% sensitive and 50-100% specific, with near-perfect inter-rater reliability. 32,33 Finally, lung pulse is the visualization of the rhythmic movement of the visceral pleura against the stationary parietal pleura resulting from cardiac pulsations through an airless and motionless left lung due to right mainstem intubation. 34,35 This technique was found to be 93% sensitive and 100% specific for detecting right mainstem intubation. 34 The lung pulse may be particularly valuable for differentiating a mainstem intubation from a pneumothorax, as both would demonstrate unilateral absence of lung sliding.

PROPOSED ALGORITHM
We propose a rapid POCUS algorithm for confirming intubation in COVID-19 patients (Figure). First, transtracheal POCUS can be used to identify endotracheal vs esophageal intubation. If there is concern with regard to location, secondary findings (eg, lung sliding) can be used. After confirming the endotracheal location, bilateral lung sliding or diaphragmatic excursion should be used to identify whether a mainstem intubation has occurred. If there is ambiguity regarding this, lung pulse can be used to differentiate unilateral lung sliding from a pneumothorax vs a mainstem intubation. If a mainstem intubation is suggested, the clinician should slowly withdraw the ETT while visualizing the contralateral lung for the reappearance of lung sliding. This algorithm has not been prospectively validated and future studies should assess the accuracy and safety of this approach.

CONCLUSION
Post-intubation ETT confirmation of COVID-19 patients presents a significant risk of exposure to providers and may be more limited by PPE. We propose the integration of POCUS into the intubation confirmation pathway and present a novel algorithm. Future studies should assess the impact of this on provider safety and the diagnostic accuracy of the protocol compared with current methods.