Introduction: Endotracheal tube (ETT) malpositioning can result in a myriad of complications. Daily chest radiographs (CXR) is the gold standard in monitoring these complications. Point-of-care transtracheal ultrasound (TTUS) is an emerging imaging modality for ETT positioning. We compared ETT malpositioning related adverse events and diagnostic accuracy of ETT malpositioning of a combined TTUS and CXR surveillance protocol to CXR alone. Methods: We performed a randomized control trial of mechanically ventilated patients in an academic multidisciplinary ICU. In the intervention group, the clinical team was provided the results of the TTUS with CXR results to aid in clinical decision making. In the control group only CXR results were used. Adverse events included bronchial migration, vocal cord herniation, balloon rupture, unplanned extubation, and the development of aspiration pneumonia. Data was analyzed via Fisher's Exact Test. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated.

Cruz, Philip Dela1; Nguyen, Connie1; Lin, Dora2; Garcia, Brianna3; Vallangca, Gimmie2; Gonzalez, Alberto1; Munoz, Mark4; Kim, Justin1; Davison, Danielle5; Yamane, David2; Ivanovics, Sasa6 Author Information

Introduction: Neuromuscular blockade (NMB) is essential in endotracheal intubation. Peripheral IVs (PIV) commonly infiltrate causing prolonged medication effects. The pharmacokinetics of subcutaneous or depot NMB are poorly defined. We report a case of intubation complicated by PIV infiltration resulting in subcutaneous (SQ) depot of rocuronium with prolonged NMB. This case encourages the inclusion of residual NMB in the differential diagnosis for patients whose neurologic exam fails to recover. Description: A 68-year-old male with hypertension and cirrhosis was admitted with urosepsis, acute kidney injury (AKI), rhabdomyolysis, and was intubated for respiratory failure. During induction with rocuronium, ketamine, and midazolam, no drug effects were noted, due to PIV infiltration. Re-induction via a different PIV and intubation were performed, causing hypotension. Vasopressors administered via a second PIV had no effect and brief cardiac arrest occurred. Epinephrine administered via Interosseous access produced return of spontaneous circulation and resolution of hypotension. The next day, the patient remained a Glasgow Coma Scale (GCS) 3T without sedation or NMB. After exclusion of other causes, train of four (TOF) twitch and bispectral Index (BiS) monitors suggested residual NMB. An NMB reversal agent (sugammadex) was administered resulting in improvement of TOF, spontaneous movement, respiration, and GCS. Due to the unknown duration of depot rocuronium with renal and hepatic injury, he remained intubated for 72 hours, then successfully extubated. Discussion: The differential diagnosis in a comatose patient following intubation and cardiac arrest is broad. In this patient, most diagnoses were excluded prior to identifying prolonged NMB. Prolonged NMB should have been considered and investigated earlier. Neither BIS nor TOF are commonly used tools and earlier utilization may have led to prompter recognition of NMB as the etiology of his poor neurologic exam. There is a paucity of literature on the identification and management of depot NMB, limited to isolated case reports. The diagnosis of prolonged NMB should be considered in the differential of any post-procedure patient without improvement in GCS.

Chaffay, Brandon; Heekin, Mary; Cruz, Philip Dela; Yamane, David; Munoz, Mark Author Information

INTRODUCTION: There are many potential complications associated with endotracheal tube (ETTs) malpositioning in critical care settings, such as bronchial migration or vocal cord herniation. These events can prolong patient recovery and lengthen ICU stays. The goal of this study is to demonstrate that point of care ultrasound (POCUS) is noninferior to chest x-ray (CXR) in identifying proper ETT depth. METHODS: We conducted an observational cohort study of intubated patients across 4 multidisciplinary ICUs at an urban academic hospital who underwent daily POCUS assessment of ETT positioning by novice sonographers (medical students). ICU/ED physicians led 4 hour-long informal trainings to teach medical students POCUS technique. Subjects were excluded if they were COVID positive, in c-spine precautions, had recent neck surgery or planned to be extubated within 24 hours. Patient ETT position was measured using POCUS assessment (balloon cuff border ending between 3-7 tracheal rings) and compared to daily radiographic CXR landmarks (5 cm ± 2 cm above carina). Recommendations based on sonographic and radiographic landmarks were compared to assess sensitivity and specificity of POCUS to evaluate need for ETT repositioning. Statistical significance was assessed using the Clopper-Pearson binomial confidence interval. RESULTS: 20 patients were enrolled for a total of 62 ventilator-days. The cohort was majority female (55%), Black/African American (75%) and mean age 55 ± 18 years. In 58 instances (93.5%), both sonographic and radiographic landmarks agreed on maintenance of ETT position. In 1 instance (1.6%), sonographers recommended ETT repositioning while radiographic landmarks did not. In 3 instances (4.8%), ETTs appeared in place by sonographic but not radiographic landmarks. The data yields a specificity of 98.31% CI [90.91,99.96] for proper ETT placement with a negative likelihood ratio of 1.02 CI [.98, 1.05] and NPV of 95.08% CI [94.92,95.24]. CONCLUSION: The high specificity and NPV values suggest that if ETT position appears within normal limits on POCUS (tip of ETT between 3-7 tracheal rings), ETT position is likely adequately positioned even when performed by novices. Further studies should investigate the use of POCUS as a monitoring alternative and as a reliable tool post-intubation to confirm ETT depth.