Anesth Analg 2007; 105:1168-
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000278153.05254.48
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
New Methods for Direct Verification of Correct Endotracheal Tube Placement
Timothy Angelotti, MD, PhD, and
John Brock-Utne, MD, PhD
Department of Anesthesia; Stanford Life Flight Air Medical Transport Program; Stanford University; Stanford, CA; timangel{at}stanford.edu
To the Editor:
Tracheal intubation in the prehospital setting is frequently performed by personnel with various levels of training, from paramedics to flight nurses, and physicians. As discussed by von Goedecke (1), regular clinical experience is invaluable for those who must supply this service. However, in the United States, physician-manned ground and air transport services are rare, and most care is provided by either paramedics or flight nurses. To provide a higher level of care, the Commission on Accreditation of Medical Transport Systems (CAMTS—-www.camts.org) has recommended that all flight nurses perform at least one successful intubation per quarter. Following this lead, our air medical transport program requires three successful intubations per quarter as well as continued education with LMA and Combitube insertion.
Equally concerning were the results of the study by Timmermann et al. (2), demonstrating that unrecognized esophageal intubations still due occur in the prehospital setting. Although the cause of this may be multifactorial as described above (1), the common denominator is that a fool-proof method for tracheal tube verification has yet to be developed. Although end-tidal CO2 capnography and esophageal detection devices have shown sensitivities and specificities of greater than 90% in controlled environments such as the OR, their success rates are drastically lowered in cardiac arrest and trauma patients, two populations commonly served in the prehospital setting (3). We suggest that this decrease in success is due in part to the fact that these modalities rely on indirect methods for verifying tracheal tube position. Although Timmermann et al. used the only direct verification method available, namely repeat direct laryngoscopy, this is not a preferred method for patients with possible cervical spine injuries.
Recently, we examined the use of a battery operated, hand-held, nondirectional fiberoptic bronchoscope (3). Using our flight nurse crew for the study, we determined that it had similar specificity to capnography with only a slight drop in sensitivity. We found that our flight crew could quickly learn to interpret fiberoptic images and discern tracheal from esophageal intubations. Fiberoptic bronchoscopes also could provide the prehospital care provider with more direct information concerning the depth of insertion as well as other injuries. Although the cost may be slightly prohibitive for some providers (approximately $1200), we believe it is time that newer and more direct modalities for verification of tracheal tube placement be developed.
Footnotes
Dr. Timmerman does not wish to respond.
REFERENCES
- von Goedecke A, Herff H, Paal P, Dorges V, Wenzel V. Field airway management disasters. Anesth Analg 2007;104:481–3[Free Full Text]
- Timmermann A, Russo SG, Eich C, Roessler M, Braun U, Rosenblatt WH, Quintel M. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007;104:619–23[Abstract/Free Full Text]
- Angelotti T, Weiss EL, Lemmens HJM, Brock-Utne J. Verification of endotracheal tube placement by prehospital providers: is a portable fiberoptic bronchoscope of value? Air Med J 2006;25:74–8[Medline]
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Do Patients Need Oxygen in Their Lungs or a Cuff in Their Trachea?
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