Training Day: Combining forces to verify tube placement
Tim Nowak // June 2, 2021
Sponsored by Bound Tree Medical
Are you in the right spot? Are you really ventilating the lungs, or is it the stomach that’s resonating chest sounds? How can you be certain?
Verifying endotracheal tube placement is of the utmost importance in managing your intubated patient’s airway. In fact, it’s critical.
From day one in your airway management lecture – be it as an EMT or as a paramedic – whenever a supraglottic airway device or endotracheal tube is inserted into the patient’s mouth, the rest of the discussion revolves around the importance of airway verification. We practice proper techniques, discuss troubleshooting, provide countless ventilations, wash, rinse and repeat (over and over again).
This skill should be able to be performed without hesitation and with 100% confidence (not 100% ignorance – or even worse, 100% arrogance).
Whether you’re in your initial training program, attending a continuing education session, completing your daily intubation challenge or advancing to a critical care training program, there’s a lot to be said, heard and seen with regard to endotracheal tube placement verification (and proper training to get you there).
AIRWAY MANAGEMENT: START WITH THE BASICS
Look, listen and feel ... seems pretty elementary. Training respective to airway management starts with the basics of watching the tube pass the through the cords (endotracheal tube, that is), listening to the stomach (first) then the lungs with your stethoscope (auscultation), and then feeling – actually put your hands on the patient’s chest to feel the chest wall rise and fall with each ventilation.
Combined with other basic, old-school options like looking for tube fogging, utilizing an esophageal tube detector device or connecting a colorimetric capnometer (which is all but phased out of most algorithms for many), starting with the basics is a great way to get your intubation onto (or, into) the right path.
INCORPORATING VIDEO LARYNGOSCOPY
Whether this is the standard or backup practice for your agency, video laryngoscopy has certainly entered the EMS/prehospital market in full force.
What’s important to emphasize in VL training is to utilize the proper tools, techniques and positioning respective to each vendor’s device. Using a hyper-curved, channel blade is different than a standard-curved, unchanneled blade. So is operating with a video screen connected to the laryngoscope handle, rather than separate and located at the patient’s side.
Rigid versus flexible stylets can also be a game changer in this equation. Make sure that each provider fully understands everything related to the equipment they’re using. This is paramount when it comes to properly intubating your patient and verifying that the tube is in the right place.
CAPNOGRAPHY: THE GOLD STANDARD
We could spend an entire week talking and training on the subject of capnography, which includes not only the end-tidal carbon dioxide – EtCO2 – value, but the capnograph waveform as well.
Needless to say, capnograph verification is seen as the gold standard in airway device placement verification for nearly all EMS agencies. What’s not always emphasized in training, however, is when your capnograph (and EtCO2) doesn’t match your patient’s presentation or when the alarms sound and put an uneasy feeling in your gut.
What if something’s wrong? What if my endotracheal tube is no longer in the trachea – now what? Should you pull the tube, manually bag-mask ventilate and retry? What about inserting a bougie before you extubate to assure proper replacement if you, indeed, had your tube in the trachea?
What other next steps or troubleshooting actions can be taken to train on airway placement verification?
GET AN INSIDE LOOK WITH ULTRASOUND
Enter into the equation ultrasound. It’s not only for assessing for a "hot belly" (bleeding into the abdomen) or for "marching ants" and "bar codes" (normal versus pneumothorax patterns). Ultrasound can also be used for visualizing tube placement in either the patient’s trachea or esophagus.
Put your crews into the situation of an inter-facility transfer, a departing scene flight or even an ROSC scenario while transporting an intubated patient. Early into the departure, your EtCO2 alarm begins to sound (low value) and your waveform disappears. Crew members check their connections, auscultate for lung sounds, watch for chest rise ... everything seems OK. Yet, the alarm still sounds. How can you increase your confidence and certainty that your tube remains seated in correct place?
Ultrasound technology – now available right in the palm of your hand – can provide you with the verification that you need by enabling you to “see” where your tube is placed. It can help to give you a TRUE (tracheal rapid ultrasound exam) result with confidence.
We have the training. We have the tools. We have no excuses, and our continued education and training should authenticate that. Taking this one step further, we need to properly and thoroughly document our findings, actions and re-evaluations with respect to airway management on each and every call.
Verifying airway placement is a multi-step, multi-tool and multi-approach process. We need to combine forces, both in the classroom with training and in the back of the ambulance when treating patients to provide proper, high-quality clinical care.