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TECHNOLOGY, COMPUTING, AND SIMULATION

Identification of Endotracheal Tube Malpositions Using Computerized Analysis of Breath Sounds via Electronic Stethoscopes

Christopher J. O’Connor, MD^*, Hansen Mansy, PhD, Robert A. Balk, MD, Kenneth J. Tuman, MD^*, and Richard H. Sandler, MD

*Department of Anesthesiology, Department of Pediatrics, Department of Pulmonary Medicine and Critical Care, Rush Medical College at Rush University Medical Center, Chicago, Illinois

Address correspondence to Christopher J. O’Connor, MD, Department of Anesthesiology, Rush Medical College at Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612. Address electronic mail to: christopher_oconnor{at}rush.edu.

Endotracheal tube (ETT) malpositioning into a mainstem bronchus or the esophagus may result in significant hypoxemia. Current methods to determine correct ETT position include auscultation, radiography, and bronchoscopy, although the current acceptable standard procedure for proper endotracheal (versus esophageal) intubation is detection of end-tidal carbon dioxide (ETco₂) by capnography, capnometry, or colorimetric ETco₂ devices. Unfortunately, capnography may be unavailable or unreliable in nonhospital/emergency settings or in low cardiac output states, and it does not detect endobronchial intubation. The purpose of this study was to quantify and assess breath sound characteristics using electronic stethoscopes placed over each hemithorax and epigastrium to determine their ability to detect ETT malposition. We recorded breath sounds in 19 healthy, non-obese adults before general surgical procedures. After intubation of the trachea, the ETT was bronchoscopically positioned 3 cm above the carina, after which 3 breaths of 500 mL were given and breath sounds were recorded. A second ETT was placed in the esophagus and the same series of breaths and recordings were performed. Finally, the tracheal ETT was advanced into the right mainstem bronchus and breath sounds were recorded. Using computerized analysis, breath sounds were digitized and filtered to remove selected frequencies, and acoustic signals and energy ratios were obtained for all 3 positions. Total energy ratios using band-pass filtering of the acoustic signals accurately identified all esophageal and endobronchial intubation (P < 0.001). These preliminary results suggest that this technique, when incorporated into a 3-component, electronic stethoscope-type device, may be an accurate, portable mechanism to reliably detect ETT malposition in adults when ETco₂ may be unavailable or unreliable.

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