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Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, ninos-j.joseph{at}advocatehealth.com
To the Editor:
The recently published case report by Reier and Reier (1) describes an elegant use of radiologic-assisted tracheal intubation in a patient with a compromised cervical spine. Successful tracheal intubation was accomplished over a multipurpose angiographic catheter guided by fluoroscopic lateral views, which were mandated by the patient’s cervical spine pathology requiring a motionless technique.
We would like to comment on the accuracy of radiologic imaging in distinguishing placement of a catheter (or a tube) in the trachea from placement in the esophagus. Studies indicate that unless the catheter (or a tube) is located in a mainstem bronchus or in the lower esophagus (beyond the carina), radiologic imaging may not be a fail-safe technique for confirmation of correct placement. (2–4) Because a tube in the esophagus is often projected over the tracheal air column on anteroposterior chest radiographs, the radiologic features of esophageal intubation are usually difficult to assess. (2–4) A study of chest radiographs of the tracheal tube position relative to nasogastric tube position provided evidence that the tube location could be identified correctly in 92% of cases with the patient in a 25-degree right posterior oblique position with the head turned to the right side. (3) Because the esophagus is located slightly to the left and behind the trachea, this projection presents the relationship en face with respect to the radiologic beam, resulting in avoidance of superimposition of the trachea over the esophagus. (3) Although a lateral view could precisely reveal esophageal or tracheal placement, there are no such studies to document that this technique is fail-safe or even near fail-safe. Until such information is available, we should be cautious about the validity of radiologic-assisted tracheal intubation.
References
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