Clinical Practice and Cases in Emergency Medicine

Introduction: Point-of-care ultrasound (POCUS) is well established as a useful adjunct for airway management in both adult and pediatric patients, including confirmation of successful endotracheal intubation. While suprasternal ultrasound of the trachea is the most described method for confirming endotracheal tube (ETT) placement, a focused lung exam can be used to rapidly identify appropriate ventilation in otherwise apneic patients.

Case Report: This case involves a one-month-old male infant who experienced an out-of-hospital cardiac arrest secondary to suspected sudden infant death syndrome. During resuscitation, an accidental extubation occurred after an attempt at securing the ETT with a commercial pediatric tube holder. Loss of end-tidal carbon dioxide (ETCO2) waveform was recognized immediately; however, emergency medical services clinicians questioned the device’s accuracy due to earlier failures of the ETCO2 monitor and the ETT remaining secured at an expected depth. A rapid POCUS lung examination demonstrated absence of bilateral lung sliding. The patient was immediately extubated, revealing a kinked ETT in the oropharynx with the distal tip positioned above the vocal cords. A supraglottic airway device (SGA) was placed with a successful return of ETCO2 waveform, followed shortly by successful reintubation because of difficulty ventilating through the SGA.

Conclusion: Lung ultrasound is a rapid and effective alternative for identifying ETT dislodgment when conventional verification methods are unreliable or unavailable. As ultrasound becomes increasingly available in prehospital and resource-limited settings, it may be effectively used by nonphysician clinicians to confirm airway placement and detect airway complications.