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

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Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it.

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He got his wrist pain from over-aggressive high-fives.

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Hello Ultrasound Podcast listeners, welcome to the first Ultrasound Podcast Little Itty Bitty.

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We were going to call this something more cool, like an ultrasound podcast wee...

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But, we realized that Weingart has already trademarked 'Wee', and we had too many copyright suits out already.

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We've been trying to figure out how to better steal people's ideas without getting in trouble,

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We're calling this a Little Itty Bitty, not a Wee...but the idea is the same.

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Super short little episodes, that we think are important to talk about.

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That we're not really motivated enough to make a whole podcast.

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

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In his last episode, he mentioned us talking about confirming tube placement using ultrasound.

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We've already done one episode on the US guided cric.

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Keith Curtis described this method of using the US to identify the cricothyroid membrane.

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And get a tube in it more quickly in the obese patient than just by landmarks.

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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.

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One was in a really bad burn patient with basically, no landmarks.

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And the other, was in a super-obese patient.

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

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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.

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That we're teaching you about.

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You are all amazing.

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And make it fully worth it to make these podcasts.

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So, here it is Scott...a little itty bitty on tube placement confirmation via US.

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Now Scott mentioned looking at the lung for sliding to confirm mainstemmed intubation versus good placement.

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Which is a great thing to do.

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And here he is talking about it.

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

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

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You could do an US too.

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One way to do it is to slowly advance the tube until the left sided lung sliding disappears. 


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And at that point you pull back around 3cm-4cm. Then you 'll have a very nice tube position.

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Or you could actually look for the tube cuff in the trachea - it's a little harder.

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And these will hopefully all go up on the US podcast...Mike/Matt hopefully you're listening.

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So...what's Scott talking about here.

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He's talking about using the linear probe and evaluating the patient's chest for the presence of lung sliding.

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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

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So, how do you do it?

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Well...you're going to use the linear probe, place it on the patient's chest.

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

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

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You put the probe marker, typically towards the patient's head.

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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.

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And you'll get something that looks sorta like this.

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Rib shadow here, and rib shadow here.

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And then there's this bright white line between the rib shadows.

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It's your pleural line.

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Where the visceral and parietal pleura connect.

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When there sliding against one-another, we see this little shimmering occuring.

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We call this pleural sliding.

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Really, an easily visible thing, especially if the patient is breathing.

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And you'll typically see these when you bag the patient.

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If you're not bagging the patient, you're not going to see sliding.

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So, the technique is to try to find something that looks like this.

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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.

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Where there is a rib shadow here, and a rib shadow here...

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and then, there's the pleural line, but there's no sliding along the pleural line.

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So I want you to do is, you'll want to look on both the right and left side.

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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.

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Here were looking at the patient's right side and you see sliding.

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But then we look at the left side and we don't see any sliding at all.

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That tells us that we're right mainstemmed.

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And then what Scott's saying is that you pull back until you see sliding on both sides.

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Like this...

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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.

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So we know that we are no longer right mainstemmed.

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

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And this really makes sense.

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This is physiology, this is really basic ultrasound understanding.

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If we're aerating that lung, we're going to get sliding along that pleural line.

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This is a great tip, and really like the real-timeness of it.

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Yes...timeness is a word (at least in Kentucky).

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Personally, I use this more as confirmation, rather than real time visualization.

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I look at sliding while everyone else is auscultating after the intubation.

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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.

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And it only disappears after intubation, when you mainstem it and isolate that lung.

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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.

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Then it's probably a pneumo.

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Avoid this by looking prior to placement, while bagging.

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Now...did Weingart totally make this up?

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No, there's some pretty good evidence for using it.

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Just like any good ultrasound idea than anyone ever has, Blaivas has already studied it.

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

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To confirm whether he was in the esophagus or trachea.

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And here are the results.

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Pretty awesome..

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There were two different operators, one was 95% sensitive and the other was 100%.

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And they were both 100% specific.

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For telling whether the tube went in the trachea or esophagus.

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Now Scott was talking about position, as to whether or not it was right mainstemmed or not...

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And they looked at that as well...

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It turns out it, that's not quite as good.

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As you can see here - their sensitivity was quite a bit lower...

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So not as good at telling if its in the esophagus or trachea.

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Here's another study, more recent from resuscitation...

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Where they had somewhat better results in trying to identify single-lung intubations.

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

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Pretty good.

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Not perfect.

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So it's hard to say this is a sure thing, like the trachea versus esophagus.

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But not bad.

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And the had less than 10 total patients they got single lung intubated.

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So, I'm not sure what to make of the 88%.

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But it's something for you to think about.

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

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Specificity for mainstem intubation was 50% in this study.

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So don't do this.

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They did comment that it was 8minutes quicker than xray.

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But it was wrong.

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Sliding is better, like in the Blaivas study, but still not great for mainstem or not.

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

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

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That would be really cool to see.

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These were static measures that I just showed you the studies for.

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A dynamic measure like that, may actually be useful and really good.

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I think someone should actually study this Weingart method.

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So I had also mentioned viewing the balloon in the cords.

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This looks like this - and is also useful.

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But if you are confirming after intubation, I think that good lung sliding while bagging the tube is much easier.

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

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What is super useful and fun, is real time visualization of the tube placement.

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This is really cool.

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

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As you've got higher success rates, and less cranking on the person.

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i.e. better care...

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It's how I would want myself, or my family intubated.

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

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However, residents and new trainees need to be able to use the normal blade.

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

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

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

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

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But I think they should get comfortable with actual steel.

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It definitely makes me less comfortable though when I am teaching them this way.

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Since I can't see what's going on.

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But super nerve-wracking no more!

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Now I just quietly, relaxed, place the probe on the neck.

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And get this picture of the trachea, and the esophagus.

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Then I ask them, "what do you see?"

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ughhhh......I think I see the cord, I'm passing through the cord.

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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).

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So then they pull back just a bit, and try again.

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And then I see this.

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The espophagus, the trachea.

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And as the tube passes through the trachea, I see it light up. Just like that.

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And then I know it was definitely through the cords.

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

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Not really...I wish I was that cool.

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I'm actually still sweating it, and waiting for the CO2 monitor to turn yellow.

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Listening to both side, and looking for sliding.

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But I'm trying to do it all while looking somewhat cool.

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I definitely have a reputation to look after.

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And again, I'm not totally making this up.

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It's been studied a fair amount.

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

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And these guys were pretty awesome.

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But is it true that you could do this in the ED (Not in elective intubation)?

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Well, this other group studied this in the tracheo-rapid US exam or TRUE study.

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And they too were awesome.

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Prospective, real ED intubations, 98.2% accuracy!

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So, what doesn't work for looking at the neck for tube placement?

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Well, you can't really look after the fact.

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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.

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

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When compared to the dynamic view.

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Watching it in real time.

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You have to watch it while it's happening, not afterwards.

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

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Watch the neck, watch for sliding bilaterally.

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It's all information you can put together in your overall assessment.

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So, a real quick how-to and logistic discussion.

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First, it's at the suprasternal notch.

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Much lower than what you're probably expecting.

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Not at the cricothyroid membrane, but lower to get this view.

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I prefer the curvilinear probe, with the depth adjusted as shallow as it could go.

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And as you can see I have the probe here on Mike's neck, midline.

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And you can't really see the esophagus because it is hidden behind the trachea.

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

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However, if you move the probe to the side, kind of oblique.

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Just as you see on Mike's neck here.

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You can definitely see the esophagus, right beside the trachea.

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

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It's super easy to see that esophagus slide out.

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Just like you can see it light up as you passed the air filled tube through it.

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Hopefully not, but if you're resident or someone else did.

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If you're showing a video it's always the resident, it's not you.

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Now, you probably want a protocol, right?

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Well, too bad.

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I'm not interested in giving you a protocol for this.

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What I want is to give you mad skillz.

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

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Practice on some cadavers.

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And try it out in some non-emergent conditions first.

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Then go for it.

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Use what you need, when you need it.

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Obviously this does not replace capnography, xray, and other means of confirmation.

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But it's one more piece of data in real time.

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Sometimes, very helpful.


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

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So, I like it!

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And I think Mikey likes it too.

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Right Mike?

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

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And I think the most interesting aspect of this is using the dynamic US.

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To really ensure that the resident or whoever the provider is, really has the tube in the right place.

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Because, I think it is ridiculously easy to tell whether it is going into the esophagus or trachea.

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As far as what Scott's talking about - using US for placement of the tube.

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And determining whether you've got a right or left mainstem.

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I think that's really interest, and their isn't a lot of research on that.

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But I did find a case series.

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Reported by none other than Mike Blaivas.

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Looking at POCUS for sonographic detection of ETT mainstem intubation.

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

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Basically lost lung sliding on the right when they looked with US after intubation.

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And they looked because they had decreased breath sounds on the right side.

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And what they ended up doing in most of these cases was pulling the tube back 2-3cm.

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So you should check it out, it's in the Journal of US.

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And pretty cool stuff.

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Matt: I've got 2 important pieces of new for you.

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1) If you've made it this far we've got bonus clip for you from Casey Parker at broomedocs.com.

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2) You can quit emailing me about finding a replacement for Mike because I found him.

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You already know that Casey is brilliant, from reading posts on his broomedocs blog.

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2 days ago he sent me this clip from the chapter he's writing for Introduction to Bedside US Volume 2.

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On the Secondary US Survey in Trauma.

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It's related to this topic, so I wanted to throw it in here.

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Now the stethoscope can still be a very useful tool in this process.

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He's brilliant, hilarious and Australian.

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You're in a busy trauma and your resident's just intubated the patient.

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And the sats are really staying in the low 90s.

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Pressure alarm on the ventilator is going off.

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You realize that something's not quite right.

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So you pick up your linear probe and place it on the left chest wall.

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And you look at what's going on there.

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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.