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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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.

That we're teaching you about.

You are all amazing.

And make it fully worth it to make these podcasts.

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

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

Which is a great thing to do.

And here he is talking about it.

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

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

You could do an US too.

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

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

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

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

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

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

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

So, how do you do it?

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

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

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

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

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.

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

Rib shadow here, and rib shadow here.

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

It's your pleural line.

Where the visceral and parietal pleura connect.

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

We call this pleural sliding.

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

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

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

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

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.

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

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

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

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.

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

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

That tells us that we're right mainstemmed.

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

Like this...

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.

So we know that we are no longer right mainstemmed.

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

And this really makes sense.

This is physiology, this is really basic ultrasound understanding.

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

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

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

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

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

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.

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

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.

Then it's probably a pneumo.

Avoid this by looking prior to placement, while bagging.

Now...did Weingart totally make this up?

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

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

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

To confirm whether he was in the esophagus or trachea.

And here are the results.

Pretty awesome..

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

And they were both 100% specific.

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

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

And they looked at that as well...

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

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

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

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

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

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

Pretty good.

Not perfect.

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

But not bad.

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

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

But it's something for you to think about.

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

Specificity for mainstem intubation was 50% in this study.

So don't do this.

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

But it was wrong.

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

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

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

That would be really cool to see.

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

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

I think someone should actually study this Weingart method.

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

This looks like this - and is also useful.

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

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

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

This is really cool.

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

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

i.e. better care...

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

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

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

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

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

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

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

But I think they should get comfortable with actual steel.

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

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

But super nerve-wracking no more!

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

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

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

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

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).

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

And then I see this.

The espophagus, the trachea.

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

And then I know it was definitely through the cords.

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

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

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

Listening to both side, and looking for sliding.

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

I definitely have a reputation to look after.

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

It's been studied a fair amount.

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

And these guys were pretty awesome.

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

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

And they too were awesome.

Prospective, real ED intubations, 98.2% accuracy!

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

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

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.

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

When compared to the dynamic view.

Watching it in real time.

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

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

Watch the neck, watch for sliding bilaterally.

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

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

First, it's at the suprasternal notch.

Much lower than what you're probably expecting.

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

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

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

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

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

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

Just as you see on Mike's neck here.

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

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

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

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

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

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

Now, you probably want a protocol, right?

Well, too bad.

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

What I want is to give you mad skillz.

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

Practice on some cadavers.

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

Then go for it.

Use what you need, when you need it.

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

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

Sometimes, very helpful.

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

So, I like it!

And I think Mikey likes it too.

Right Mike?

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

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

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

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

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

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

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

But I did find a case series.

Reported by none other than Mike Blaivas.

Looking at POCUS for sonographic detection of ETT mainstem intubation.

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

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

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

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

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

And pretty cool stuff.

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

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

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

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

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

On the Secondary US Survey in Trauma.

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

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

He's brilliant, hilarious and Australian.

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

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

Pressure alarm on the ventilator is going off.

You realize that something's not quite right.

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

And you look at what's going on there.

At first glance, it looks like normal lung sliding.

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

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

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

This is the lung pulse-sign.

Of a normally expanded, but non-ventilated lung.

Most likely a right mainstem bronchus.

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

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

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

I usually get my stethoscope at this point.

And use it to strangle the resident.

That way everyone learns something from the experience.