0:00:00.669,0:00:05.971
If you're not good enough at Ultrasound, that's not an excuse to punish your patients with radiation.

0:00:05.971,0:00:11.232
Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it.

0:00:11.232,0:00:15.354
He got his wrist pain from over-aggressive high-fives.

0:00:15.354,0:00:20.207
Hello Ultrasound Podcast listeners, welcome to the first Ultrasound Podcast Little Itty Bitty.

0:00:20.207,0:00:23.705
We were going to call this something more cool, like an ultrasound podcast wee...

0:00:23.705,0:00:30.011
But, we realized that Weingart has already trademarked 'Wee', and we had too many copyright suits out already.

0:00:30.011,0:00:34.169
We've been trying to figure out how to better steal people's ideas without getting in trouble,

0:00:34.169,0:00:38.099
We're calling this a Little Itty Bitty, not a Wee...but the idea is the same.

0:00:38.099,0:00:42.391
Super short little episodes, that we think are important to talk about.

0:00:42.391,0:00:47.322
That we're not really motivated enough to make a whole podcast.

0:00:47.322,0:00:51.558
So, in honour of EMCRIT (who we plagiarized the idea from), we're going to take a suggestion from Scott.

0:00:51.558,0:00:57.966
In his last episode, he mentioned us talking about confirming tube placement using ultrasound.

0:00:57.966,0:01:02.591
We've already done one episode on the US guided cric.

0:01:02.591,0:01:07.098
Keith Curtis described this method of using the US to identify the cricothyroid membrane.

0:01:07.098,0:01:11.298
And get a tube in it more quickly in the obese patient than just by landmarks.

0:01:11.298,0:01:21.951
This was published recently in Academic EM, but even before that, we got emails from you guys - the listeners - about 2 cases where using this, made a real difference.

0:01:21.951,0:01:25.410
One was in a really bad burn patient with basically, no landmarks.

0:01:25.410,0:01:28.659
And the other, was in a super-obese patient.

0:01:28.659,0:01:34.731
We've got images from both of those cases and we hope to have the stories for you sometime in the near future.

0:01:34.731,0:01:42.109
That's kinda old news, but I wanted to mention it because I am always happily surprised when I hear that you guys are actually doing this stuff.

0:01:42.109,0:01:44.643
That we're teaching you about.

0:01:44.643,0:01:46.207
You are all amazing.

0:01:46.207,0:01:48.637
And make it fully worth it to make these podcasts.

0:01:48.637,0:01:54.950
So, here it is Scott...a little itty bitty on tube placement confirmation via US.

0:01:54.950,0:01:59.424
Now Scott mentioned looking at the lung for sliding to confirm mainstemmed intubation versus good placement.

0:01:59.424,0:02:01.339
Which is a great thing to do.

0:02:01.339,0:02:03.437
And here he is talking about it.

0:02:03.437,0:02:06.662
SW: Ok, now we're going to think about checking tube depth.

0:02:06.662,0:02:11.911
And that usually, in conventional EDs means an xray...and that's fine. You NEED an xray at some point post-intubation.

0:02:11.911,0:02:16.188
You could do an US too.

0:02:16.188,0:02:21.989
One way to do it is to slowly advance the tube until the left sided lung sliding disappears. [br]

0:02:21.989,0:02:29.008
And at that point you pull back around 3cm-4cm. Then you 'll have a very nice tube position.

0:02:29.008,0:02:34.023
Or you could actually look for the tube cuff in the trachea - it's a little harder.

0:02:34.023,0:02:40.127
And these will hopefully all go up on the US podcast...Mike/Matt hopefully you're listening.

0:02:40.127,0:02:43.185
So...what's Scott talking about here.

0:02:43.185,0:02:47.836
He's talking about using the linear probe and evaluating the patient's chest for the presence of lung sliding.

0:02:47.836,0:02:55.068
And the concept is that...if you are actually aerating the patient's lung, there's going to be lung sliding seen using that linear probe

0:02:55.068,0:02:56.957
So, how do you do it?

0:02:56.957,0:03:00.200
Well...you're going to use the linear probe, place it on the patient's chest.

0:03:00.200,0:03:05.854
Usually, around the mid-clavicular line. (I usually use the mid-clavicular line on the right and the anterior axillary line on the left).

0:03:05.854,0:03:09.470
But, it doesn't matter - as long as you see good lung tissue and can see the pleural line.

0:03:09.470,0:03:11.540
You put the probe marker, typically towards the patient's head.

0:03:11.540,0:03:18.977
And you'll sort of be in this sagital section, so you'll be looking between the rib spaces and you can see the rib shadows.

0:03:18.977,0:03:22.076
And you'll get something that looks sorta like this.

0:03:22.076,0:03:25.544
Rib shadow here, and rib shadow here.

0:03:25.544,0:03:27.925
And then there's this bright white line between the rib shadows.

0:03:27.925,0:03:29.225
It's your pleural line.

0:03:29.225,0:03:31.317
Where the visceral and parietal pleura connect.

0:03:31.317,0:03:33.539
When there sliding against one-another, we see this little shimmering occuring.

0:03:33.539,0:03:39.610
We call this pleural sliding.

0:03:39.610,0:03:43.069
Really, an easily visible thing, especially if the patient is breathing.

0:03:43.069,0:03:45.799
And you'll typically see these when you bag the patient.

0:03:45.799,0:03:50.703
If you're not bagging the patient, you're not going to see sliding.

0:03:50.703,0:03:54.407
So, the technique is to try to find something that looks like this.

0:03:54.407,0:03:59.679
This is an example of what you would see if you saw at pneumothorax or if you had say a right mainstem, and you're looking at the patient's left side.

0:03:59.679,0:04:02.010
Where there is a rib shadow here, and a rib shadow here...

0:04:02.010,0:04:06.560
and then, there's the pleural line, but there's no sliding along the pleural line.

0:04:06.560,0:04:11.391
So I want you to do is, you'll want to look on both the right and left side.

0:04:11.391,0:04:18.680
And the first thing you'll do is basically push the tube down to the point where you'll only see sliding on the patient's right side.

0:04:18.680,0:04:23.370
Here were looking at the patient's right side and you see sliding.

0:04:23.401,0:04:26.542
But then we look at the left side and we don't see any sliding at all.

0:04:26.542,0:04:28.317
That tells us that we're right mainstemmed.

0:04:28.317,0:04:30.888
And then what Scott's saying is that you pull back until you see sliding on both sides.

0:04:30.888,0:04:33.132
Like this...

0:04:33.132,0:04:38.808
So now we're looking on the right side and we're seeing good sliding, and then again we're looking on the left side and we have good sliding.

0:04:38.808,0:04:41.330
So we know that we are no longer right mainstemmed.

0:04:41.330,0:04:46.513
And then Scott's saying you just pull back an additional 3cm, and that way you know you're in an adequate place.

0:04:46.513,0:04:49.159
And this really makes sense.

0:04:49.159,0:04:53.570
This is physiology, this is really basic ultrasound understanding.

0:04:53.570,0:04:58.669
If we're aerating that lung, we're going to get sliding along that pleural line.

0:04:58.669,0:05:01.526
This is a great tip, and really like the real-timeness of it.

0:05:01.526,0:05:03.749
Yes...timeness is a word (at least in Kentucky).

0:05:03.749,0:05:08.788
Personally, I use this more as confirmation, rather than real time visualization.

0:05:08.788,0:05:13.511
I look at sliding while everyone else is auscultating after the intubation.

0:05:13.511,0:05:22.015
Obviously if you're going to do this though, you should look prior to intubation while bagging as well, to make sure the absence of sliding you see is not a pneumo.

0:05:22.015,0:05:26.810
And it only disappears after intubation, when you mainstem it and isolate that lung.

0:05:26.810,0:05:34.124
If you continually back the tube up while looking for sliding to start again, until the whole thing is floating above the patient's head.

0:05:34.124,0:05:36.438
Then it's probably a pneumo.

0:05:36.438,0:05:39.260
Avoid this by looking prior to placement, while bagging.

0:05:39.260,0:05:42.283
Now...did Weingart totally make this up?

0:05:42.283,0:05:44.711
No, there's some pretty good evidence for using it.

0:05:44.711,0:05:48.800
Just like any good ultrasound idea than anyone ever has, Blaivas has already studied it.

0:05:48.800,0:05:56.304
In this study, he intubated a bunch of cadavers with a couple of other guys, and watched for lung sliding after the intubation.

0:05:56.304,0:05:59.456
To confirm whether he was in the esophagus or trachea.

0:05:59.456,0:06:02.611
And here are the results.

0:06:02.611,0:06:04.697
Pretty awesome..

0:06:04.697,0:06:09.343
There were two different operators, one was 95% sensitive and the other was 100%.

0:06:09.343,0:06:12.805
And they were both 100% specific.

0:06:12.805,0:06:15.503
For telling whether the tube went in the trachea or esophagus.

0:06:15.503,0:06:20.377
Now Scott was talking about position, as to whether or not it was right mainstemmed or not...

0:06:20.377,0:06:22.538
And they looked at that as well...

0:06:22.538,0:06:24.150
It turns out it, that's not quite as good.

0:06:24.150,0:06:28.256
As you can see here - their sensitivity was quite a bit lower...

0:06:28.256,0:06:31.520
So not as good at telling if its in the esophagus or trachea.

0:06:31.520,0:06:34.142
Here's another study, more recent from resuscitation...

0:06:34.142,0:06:37.254
Where they had somewhat better results in trying to identify single-lung intubations.

0:06:37.254,0:06:43.681
They looked at these patients bilaterally, at the mid-axillary line after intubation, and their accuracy was 88.7% for identifying single lung intubation.

0:06:43.681,0:06:45.879
Pretty good.

0:06:45.879,0:06:47.006
Not perfect.

0:06:47.006,0:06:49.244
So it's hard to say this is a sure thing, like the trachea versus esophagus.

0:06:49.244,0:06:50.872
But not bad.

0:06:50.872,0:06:55.216
And the had less than 10 total patients they got single lung intubated.

0:06:55.216,0:06:59.440
So, I'm not sure what to make of the 88%.

0:06:59.440,0:07:02.457
But it's something for you to think about.

0:07:02.457,0:07:08.100
And just to be clear about what doesn't work, you can't use diaphragm movement, like this study tried.

0:07:08.100,0:07:13.323
Specificity for mainstem intubation was 50% in this study.

0:07:13.323,0:07:14.459
So don't do this.

0:07:14.459,0:07:17.411
They did comment that it was 8minutes quicker than xray.

0:07:17.411,0:07:18.580
But it was wrong.

0:07:18.580,0:07:24.889
Sliding is better, like in the Blaivas study, but still not great for mainstem or not.

0:07:24.889,0:07:30.308
So, this really hasn't been confirmed and shown that we're good enough at telling if it was mainstemmed or not.

0:07:30.308,0:07:38.337
But I couldn't find anyone who's actually done the real time (watching the sliding) while advancing - that Weingart proposed.

0:07:38.337,0:07:39.593
That would be really cool to see.

0:07:39.593,0:07:43.418
These were static measures that I just showed you the studies for.

0:07:43.418,0:07:47.332
A dynamic measure like that, may actually be useful and really good.

0:07:47.332,0:07:50.552
I think someone should actually study this Weingart method.

0:07:50.552,0:07:54.027
So I had also mentioned viewing the balloon in the cords.

0:07:54.027,0:07:56.673
This looks like this - and is also useful.

0:07:56.673,0:08:03.216
But if you are confirming after intubation, I think that good lung sliding while bagging the tube is much easier.

0:08:03.216,0:08:07.528
And we've got great evidence for that, to tell whether or not it is in the esophagus or trachea.

0:08:07.528,0:08:14.003
What is super useful and fun, is real time visualization of the tube placement.

0:08:14.003,0:08:15.118
This is really cool.

0:08:15.118,0:08:21.903
Now, like many others of you out there, I primarily use the glidescope, and have my residents use it as well.

0:08:21.903,0:08:25.625
As you've got higher success rates, and less cranking on the person.

0:08:25.625,0:08:26.816
i.e. better care...

0:08:26.816,0:08:29.553
It's how I would want myself, or my family intubated.

0:08:29.553,0:08:36.562
And when we use the video laryngoscope, I can watch, exactly what's going on, on the video - in real time.

0:08:36.562,0:08:43.680
However, residents and new trainees need to be able to use the normal blade.

0:08:43.680,0:08:47.417
So for newer intubators, I will have them try direct laryngoscopy first with glidescope next to us - ready as needed.

0:08:47.417,0:08:56.394
And this use to be a somewhat nerve-wracking experience, as they are new users and I can't really see what is happening.

0:08:56.394,0:09:03.203
It always amazed me how of then they could definitely see the cords if I asked, but it ended up in the goose somehow.

0:09:03.203,0:09:08.755
Now I know I could have them use the glidescope as a direct laryngoscope, and only look at the screen myself.

0:09:08.755,0:09:14.120
But I think they should get comfortable with actual steel.

0:09:14.120,0:09:18.098
It definitely makes me less comfortable though when I am teaching them this way.

0:09:18.098,0:09:20.329
Since I can't see what's going on.

0:09:20.329,0:09:23.374
But super nerve-wracking no more!

0:09:23.374,0:09:27.481
Now I just quietly, relaxed, place the probe on the neck.

0:09:27.481,0:09:32.079
And get this picture of the trachea, and the esophagus.

0:09:32.079,0:09:35.358
Then I ask them, "what do you see?"

0:09:35.358,0:09:37.567
ughhhh......I think I see the cord, I'm passing through the cord.

0:09:37.567,0:09:48.210
And then I say "Hold on there tiger! - I just saw it pass through the esophagus, why don't you pull back and try again." (in a pretty condescending voice).

0:09:48.210,0:09:50.205
So then they pull back just a bit, and try again.

0:09:50.205,0:09:55.003
And then I see this.

0:09:55.003,0:09:55.905
The espophagus, the trachea.

0:09:55.905,0:10:01.113
And as the tube passes through the trachea, I see it light up. Just like that.

0:10:01.113,0:10:05.118
And then I know it was definitely through the cords.

0:10:05.118,0:10:10.864
They ask me "How do the lungs sound?", and I say "Don't worry about it, I trust ya"...and then I walk away.

0:10:10.864,0:10:12.603
Not really...I wish I was that cool.

0:10:12.603,0:10:15.235
I'm actually still sweating it, and waiting for the CO2 monitor to turn yellow.

0:10:15.235,0:10:16.714
Listening to both side, and looking for sliding.

0:10:16.714,0:10:20.139
But I'm trying to do it all while looking somewhat cool.

0:10:20.139,0:10:22.474
I definitely have a reputation to look after.

0:10:22.474,0:10:25.186
And again, I'm not totally making this up.

0:10:25.186,0:10:27.417
It's been studied a fair amount.

0:10:27.417,0:10:34.248
In this study, they had EM doctors watch the neck sonographically during real intubation in the OR with elective surgery.

0:10:34.248,0:10:37.146
And these guys were pretty awesome.

0:10:37.146,0:10:44.351
But is it true that you could do this in the ED (Not in elective intubation)?

0:10:44.351,0:10:49.846
Well, this other group studied this in the tracheo-rapid US exam or TRUE study.

0:10:49.846,0:10:52.129
And they too were awesome.

0:10:52.129,0:10:58.462
Prospective, real ED intubations, 98.2% accuracy!

0:10:58.462,0:11:03.303
So, what doesn't work for looking at the neck for tube placement?

0:11:03.303,0:11:06.860
Well, you can't really look after the fact.

0:11:06.860,0:11:15.586
You can, and you may see a nice picture, but when you use the static method, you may see what you think is a tube in the trachea.

0:11:15.586,0:11:22.337
But what this study found, was that the sensitivity fell to 51% (From 97%) in the same intubations.

0:11:22.337,0:11:25.671
When compared to the dynamic view.

0:11:25.671,0:11:27.356
Watching it in real time.

0:11:27.356,0:11:30.708
You have to watch it while it's happening, not afterwards.

0:11:30.708,0:11:35.478
And if you're feeling really frisky....you don't have to do these things in isolation, you can combo-them up.

0:11:35.478,0:11:38.836
Watch the neck, watch for sliding bilaterally.

0:11:38.836,0:11:44.299
It's all information you can put together in your overall assessment.

0:11:44.299,0:11:49.045
So, a real quick how-to and logistic discussion.

0:11:49.045,0:11:52.090
First, it's at the suprasternal notch.

0:11:52.090,0:11:56.095
Much lower than what you're probably expecting.

0:11:56.095,0:12:00.035
Not at the cricothyroid membrane, but lower to get this view.

0:12:00.035,0:12:05.326
I prefer the curvilinear probe, with the depth adjusted as shallow as it could go.

0:12:05.326,0:12:09.064
And as you can see I have the probe here on Mike's neck, midline.

0:12:09.064,0:12:13.680
And you can't really see the esophagus because it is hidden behind the trachea.

0:12:13.680,0:12:17.491
Mike's swallowing here, but you don't really see it because it is behind the air-filled trachea.

0:12:17.491,0:12:22.030
However, if you move the probe to the side, kind of oblique.

0:12:22.030,0:12:24.807
Just as you see on Mike's neck here.

0:12:24.807,0:12:27.494
You can definitely see the esophagus, right beside the trachea.

0:12:27.494,0:12:32.962
And as he swallows, I think he was drinking a skinny sugar-free banana latte with extra whip cream.

0:12:32.962,0:12:36.466
It's super easy to see that esophagus slide out.

0:12:36.466,0:12:40.326
Just like you can see it light up as you passed the air filled tube through it.

0:12:40.326,0:12:44.832
Hopefully not, but if you're resident or someone else did.

0:12:44.832,0:12:47.597
If you're showing a video it's always the resident, it's not you.

0:12:47.597,0:12:51.389
Now, you probably want a protocol, right?

0:12:51.389,0:12:54.724
Well, too bad.

0:12:54.724,0:12:56.339
I'm not interested in giving you a protocol for this.

0:12:56.339,0:12:59.754
What I want is to give you mad skillz.

0:12:59.754,0:13:05.879
Take all this, practice on yourself, you're going to be amazed at how easy it is to see the esophagus and trachea.

0:13:05.879,0:13:08.390
Practice on some cadavers.

0:13:08.390,0:13:11.294
And try it out in some non-emergent conditions first.

0:13:11.294,0:13:14.284
Then go for it.

0:13:14.284,0:13:17.080
Use what you need, when you need it.

0:13:17.080,0:13:19.608
Obviously this does not replace capnography, xray, and other means of confirmation.

0:13:19.608,0:13:22.664
But it's one more piece of data in real time.

0:13:22.664,0:13:24.770
Sometimes, very helpful.[br]

0:13:24.770,0:13:32.598
Sometimes knowing 30s sooner than you would with capnography is really important for a sick, desating patient.

0:13:32.598,0:13:34.784
So, I like it!

0:13:34.784,0:13:37.021
And I think Mikey likes it too.

0:13:37.021,0:13:38.219
Right Mike?

0:13:38.219,0:13:41.478
Mike: I couldn't agree more Matt, this is really interesting stuff.

0:13:41.478,0:13:46.031
And I think the most interesting aspect of this is using the dynamic US.

0:13:46.031,0:13:52.817
To really ensure that the resident or whoever the provider is, really has the tube in the right place.

0:13:52.817,0:13:58.920
Because, I think it is ridiculously easy to tell whether it is going into the esophagus or trachea.

0:13:58.920,0:14:03.630
As far as what Scott's talking about - using US for placement of the tube.

0:14:03.630,0:14:07.384
And determining whether you've got a right or left mainstem.

0:14:07.384,0:14:11.292
I think that's really interest, and their isn't a lot of research on that.

0:14:11.292,0:14:15.125
But I did find a case series.

0:14:15.125,0:14:17.241
Reported by none other than Mike Blaivas.

0:14:17.241,0:14:23.689
Looking at POCUS for sonographic detection of ETT mainstem intubation.

0:14:23.689,0:14:30.659
This is really interesting because, these were just unusual cases, where they found the ETT went into the left mainstem.

0:14:30.659,0:14:36.058
Basically lost lung sliding on the right when they looked with US after intubation.

0:14:36.058,0:14:38.918
And they looked because they had decreased breath sounds on the right side.

0:14:38.918,0:14:43.814
And what they ended up doing in most of these cases was pulling the tube back 2-3cm.

0:14:43.814,0:14:47.691
So you should check it out, it's in the Journal of US.

0:14:47.691,0:14:51.400
And pretty cool stuff.

0:14:51.400,0:14:53.757
Matt: I've got 2 important pieces of new for you.

0:14:53.757,0:14:58.231
1) If you've made it this far we've got bonus clip for you from Casey Parker at broomedocs.com.

0:14:58.231,0:15:03.366
2) You can quit emailing me about finding a replacement for Mike because I found him.

0:15:03.366,0:15:06.753
You already know that Casey is brilliant, from reading posts on his broomedocs blog.

0:15:06.753,0:15:12.296
2 days ago he sent me this clip from the chapter he's writing for Introduction to Bedside US Volume 2.

0:15:12.296,0:15:16.324
On the Secondary US Survey in Trauma.

0:15:16.324,0:15:18.554
It's related to this topic, so I wanted to throw it in here.

0:15:18.554,0:15:22.719
Now the stethoscope can still be a very useful tool in this process.

0:15:22.719,0:15:24.971
He's brilliant, hilarious and Australian.

0:15:24.971,0:15:32.313
You're in a busy trauma and your resident's just intubated the patient.

0:15:32.313,0:15:36.351
And the sats are really staying in the low 90s.

0:15:36.351,0:15:39.819
Pressure alarm on the ventilator is going off.

0:15:39.819,0:15:42.552
You realize that something's not quite right.

0:15:42.552,0:15:46.481
So you pick up your linear probe and place it on the left chest wall.

0:15:46.481,0:15:49.827
And you look at what's going on there.

0:15:49.827,0:15:53.753
At first glance, it looks like normal lung sliding.

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But if you look closely, and listen to the sats monitor in the background.

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Beep.Beep.Beep.Beep.Beep.Beep.Beep.

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You'll notice these movements are time exactly with the cardiac pulsations.

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This is the lung pulse-sign.

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Of a normally expanded, but non-ventilated lung.

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Most likely a right mainstem bronchus.

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And you'll want to pull that tube back, so you can once again ventilate that lung.

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At this point, you should leave the probe on the chest wall, while you withdraw the tube.

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And you can confirm sliding once you've pulled the tube back past the carina.

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I usually get my stethoscope at this point.

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And use it to strangle the resident.

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That way everyone learns something from the experience.