Lema Penelope C, O'Brien Michael, Wilson Juliana, James Erika St, Lindstrom Heather, DeAngelis John, Caldwell Jennifer, May Paul, Clemency Brian
1University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department of Emergency Medicine,Buffalo,New YorkUSA.
2University of Colorado School of Medicine,University of Colorado Hospital Department of Emergency Medicine,Aurora,ColoradoUSA.
Prehosp Disaster Med. 2018 Aug;33(4):406-410. doi: 10.1017/S1049023X18000651.
Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation.
A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience.
During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location.
Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.
快速识别食管插管对于避免患者发病和死亡至关重要。连续波形二氧化碳描记法仍是确认气管内插管（ETT）的金标准，但它存在局限性。床旁超声（POCUS）可能是确认ETT位置的一种有用替代方法。本研究的目的是确定护理人员在有和没有ETT操作的情况下通过POCUS识别食管插管的准确性。
采用尸体模型进行了一项前瞻性观察研究。招募当地护理人员作为受试者，每人完成一份关于其人口统计学、工作经历、插管经验和先前POCUS培训的调查问卷。受试者参加了一次教学课程，在课程中他们学习了通过POCUS识别ETT位置。在每次研究过程中，研究人员将一根ETT随机放置在四具尸体的气管或食管中，并通过直接喉镜检查进行确认。然后受试者尝试在不操作和操作ETT的情况下使用POCUS确定位置。通过扭转管子来操作管子。使用描述性统计和逻辑回归来评估结果以及先前护理人员经验的影响。
在2014年3月至2015年12月的12次研究过程中，57名受试者参与，共评估了228次插管：113次气管插管和115次食管插管。受试者中84.0%为男性，平均年龄39岁（范围：22 - 62岁），中位经验为7年（范围：0.6 - 39年）。护理人员在不操作ETT的情况下正确识别ETT位置的有158例（69.3%），操作ETT的情况下有194例（85.1%）。在操作后，识别食管位置的敏感性和特异性分别从52.2%（95%置信区间[CI]，43.0 - 61.0）和86.7%（95%CI，81.0 - 93.0）提高到87.0%（95%CI，81.0 - 93.0）和83.2%（95%CI，0.76 - 0.90）（P<.0001），而特异性不受影响（P = 0.45）。受试者正确识别了41例先前错误识别的食管插管。护理人员的经验、先前的插管经历和POCUS经验与识别管子位置的能力无关。
护理人员可以通过POCUS准确识别食管插管，并且操作可提高识别率。需要进一步研究护理人员使用动态POCUS识别意外食管插管的情况。莱马PC、奥布赖恩M、威尔逊J、圣詹姆斯E、林德斯特伦H、迪安吉利斯J、考德威尔J、梅P、克莱门西B。避开“鹅”！护理人员通过超声识别食管插管。院前灾难医学。2018；33(4)：406 - 410。
