How To Determine ET Tube Placement

NoviceToExpert · Jul 9, 2008

Nothing beats a CXR to tell you how deep you are in the esophagus.

That's very funny!!!

SWEnfermera · Jul 10, 2008

Remember,

A CXR is only a 2-D image. It only tells you where the ET tube is in relationship to the level of the carina, it does not tell you if you are in the trachea or esophagus. You shouldn't rely on only one assessment tool. You should check all; sats, auscultation, ETCO2, and CXR. If even one is questionable, then question your placement.

I do agree, broncoscopy is definitely the best way to determine placement but not always available in smaller hospitals, whereas the other tools usually are.

anurseuk · Jul 13, 2008

Straight after intubation?

We would immediatly to auscultation for equal air entry etc and then confirm with CXR. Then we'd record length at which the ETT is tied and then we know if it's slipped etc later on.

You would also do an ABG and you can tell by the pt's oxygenation by comparing it to a pre intubation gas.

Hope that helps.

joeyzstj, LPN · Jul 17, 2008

Remember,
A CXR is only a 2-D image. It only tells you where the ET tube is in relationship to the level of the carina, it does not tell you if you are in the trachea or esophagus. You shouldn't rely on only one assessment tool. You should check all; sats, auscultation, ETCO2, and CXR. If even one is questionable, then question your placement.
I do agree, broncoscopy is definitely the best way to determine placement but not always available in smaller hospitals, whereas the other tools usually are.

I agree with the above, and inspection with an intubation scope isnt that wild of an idea. We have a self contained brochoscope just for this reason. Another idea would be to use a glide scope where you can easily visualize the scope passing. As SWE mentioned above, a CXR is the gold standard, however it does NOT tell you the placement in relationt to depth. You coul have proper placement as far as depth is concerned, however it could still be in the esophagus. This is where listening to breath sounds, easy capnography and check for consensation in the tube come into play. A tube should NEVER be placed unless it is directly visualized by the practitioner to pass through the vocal cords. I have intubated many people and never had an esophageal intubation due to this. In my opinion, if I had to pick ONE single way, it would be to visulaize it with a bronchoscope. In some hospitals this is quite common.

tararose · Jun 28, 2009

I am in agreement with NP Gilly. All of these modalities should be used in ET-tube placement. I am an ICU/ER nurse (over 13 years experience) and each time that we intubate we listen for bilateral breath sounds, utilize end-tidal CO2 and verify placement by chest x-ray. According to the American College of Emergency Physicians "No single technique used for confirmation of endotracheal tube placement has been proven to be 100% accurate." End-tidal carbon dioxide detection is the most accurate technology to evaluate endotracheal tube position in patients who have adequate tissue perfusion. Unfortunately, patients who are in cardiac arrest may not have adequate tissue perfusion causing inadequate results. Esophageal Detector Devices (EDD) are not comparable to ETCO2 devices. You can obtain information about ET-tube placement at American College of Emergency Physicians.

Rapid intubation includes prepping the patient (Monitor [Leads, BP, SaO2]) and accessing the airway. Teamwork saves lives. That goes for ER and ICU. An ABG is done once the patient has been intubated (emergency intubation). If an ABG is done before a patient is intubated then one would agree that it was done to determine if intubation is required.

RNAEMTCC · Jul 6, 2009

don't be fooled!

Breath sounds and end tidal co 2 measurment with a device can be decieving!

By all means. WAVEFORM CAPNOGRAPHY is the best form folks.

It's totally NON invasive, just ask the doc if you can monitor ETCO2 (they usually don't give a hoot if you want to) and you have a wonderful wave form of constant reassurance that your tube is in the right place.

perhaps it's because i can also do pre hospital intubations and have come to love waveform capnography as a wonderful reminder of where my tube is.

Given the wrong situation your color changer will be WRONG.... you can just barely right mainstem and still manage to get bilateral breath sounds.

By all means, I still use breath sounds, but something about that waveform that comes up makes me feel so much better...

besides it tells you so much about your patient!

ok, i'm off my soap box now...

sicushells, RN · Jul 6, 2009

After intubation we check bilat. breath sounds, ETCO2, and then chest xray. I've never seen all three come back (+) and then find out that the tube is in the esophagus. I suppose theoretically it's possible, but wouldn't you notice the patient's abdomen blowing up and the sats not coming up? Even if you're delivering 100% FiO2 to someone's esophagus, they're not going to be oxygenating well, lol.

hypocaffeinemia, BSN, RN · Jul 12, 2009

It's not like it's some mutually exclusive competition between the methods.

We listen x2 people for bilateral symmetrical air movement at the same time respiratory therapy is verifying via end-tidal CO2 and we're all eyeing the SpO2. Meanwhile, by that point radiology is typically outside the room ready to do the stat CXR, which we can all view instantaneously (with rad report to come later...).