WEBVTT 00:00:00.669 --> 00:00:05.971 If you're not good enough at Ultrasound, that's not an excuse to punish your patients with radiation. 00:00:05.971 --> 00:00:11.232 Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it. 00:00:11.232 --> 00:00:15.354 He got his wrist pain from over-aggressive high-fives. 00:00:15.354 --> 00:00:20.207 Hello Ultrasound Podcast listeners, welcome to the first Ultrasound Podcast Little Itty Bitty. 00:00:20.207 --> 00:00:23.705 We were going to call this something more cool, like an ultrasound podcast wee... 00:00:23.705 --> 00:00:30.011 But, we realized that Weingart has already trademarked 'Wee', and we had too many copyright suits out already. 00:00:30.011 --> 00:00:34.169 We've been trying to figure out how to better steal people's ideas without getting in trouble, 00:00:34.169 --> 00:00:38.099 We're calling this a Little Itty Bitty, not a Wee...but the idea is the same. 00:00:38.099 --> 00:00:42.391 Super short little episodes, that we think are important to talk about. 00:00:42.391 --> 00:00:47.322 That we're not really motivated enough to make a whole podcast. 00:00:47.322 --> 00:00:51.558 So, in honour of EMCRIT (who we plagiarized the idea from), we're going to take a suggestion from Scott. 00:00:51.558 --> 00:00:57.966 In his last episode, he mentioned us talking about confirming tube placement using ultrasound. 00:00:57.966 --> 00:01:02.591 We've already done one episode on the US guided cric. 00:01:02.591 --> 00:01:07.098 Keith Curtis described this method of using the US to identify the cricothyroid membrane. 00:01:07.098 --> 00:01:11.298 And get a tube in it more quickly in the obese patient than just by landmarks. 00:01:11.298 --> 00:01:21.951 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. 00:01:21.951 --> 00:01:25.410 One was in a really bad burn patient with basically, no landmarks. 00:01:25.410 --> 00:01:28.659 And the other, was in a super-obese patient. 00:01:28.659 --> 00:01:34.731 We've got images from both of those cases and we hope to have the stories for you sometime in the near future. 00:01:34.731 --> 00:01:42.109 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. 00:01:42.109 --> 00:01:44.643 That we're teaching you about. 00:01:44.643 --> 00:01:46.207 You are all amazing. 00:01:46.207 --> 00:01:48.637 And make it fully worth it to make these podcasts. 00:01:48.637 --> 00:01:54.950 So, here it is Scott...a little itty bitty on tube placement confirmation via US. 00:01:54.950 --> 00:01:59.424 Now Scott mentioned looking at the lung for sliding to confirm mainstemmed intubation versus good placement. 00:01:59.424 --> 00:02:01.339 Which is a great thing to do. 00:02:01.339 --> 00:02:03.437 And here he is talking about it. 00:02:03.437 --> 00:02:06.662 SW: Ok, now we're going to think about checking tube depth. 00:02:06.662 --> 00:02:11.911 And that usually, in conventional EDs means an xray...and that's fine. You NEED an xray at some point post-intubation. 00:02:11.911 --> 00:02:16.188 You could do an US too. 00:02:16.188 --> 00:02:21.989 One way to do it is to slowly advance the tube until the left sided lung sliding disappears. 00:02:21.989 --> 00:02:29.008 And at that point you pull back around 3cm-4cm. Then you 'll have a very nice tube position. 00:02:29.008 --> 00:02:34.023 Or you could actually look for the tube cuff in the trachea - it's a little harder. 00:02:34.023 --> 00:02:40.127 And these will hopefully all go up on the US podcast...Mike/Matt hopefully you're listening. 00:02:40.127 --> 00:02:43.185 So...what's Scott talking about here. 00:02:43.185 --> 00:02:47.836 He's talking about using the linear probe and evaluating the patient's chest for the presence of lung sliding. 00:02:47.836 --> 00:02:55.068 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 00:02:55.068 --> 00:02:56.957 So, how do you do it? 00:02:56.957 --> 00:03:00.200 Well...you're going to use the linear probe, place it on the patient's chest. 00:03:00.200 --> 00:03:05.854 Usually, around the mid-clavicular line. (I usually use the mid-clavicular line on the right and the anterior axillary line on the left). 00:03:05.854 --> 00:03:09.470 But, it doesn't matter - as long as you see good lung tissue and can see the pleural line. 00:03:09.470 --> 00:03:11.540 You put the probe marker, typically towards the patient's head. 00:03:11.540 --> 00:03:18.977 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. 00:03:18.977 --> 00:03:22.076 And you'll get something that looks sorta like this. 00:03:22.076 --> 00:03:25.544 Rib shadow here, and rib shadow here. 00:03:25.544 --> 00:03:27.925 And then there's this bright white line between the rib shadows. 00:03:27.925 --> 00:03:29.225 It's your pleural line. 00:03:29.225 --> 00:03:31.317 Where the visceral and parietal pleura connect. 00:03:31.317 --> 00:03:33.539 When there sliding against one-another, we see this little shimmering occuring. 00:03:33.539 --> 00:03:39.610 We call this pleural sliding. 00:03:39.610 --> 00:03:43.069 Really, an easily visible thing, especially if the patient is breathing. 00:03:43.069 --> 00:03:45.799 And you'll typically see these when you bag the patient. 00:03:45.799 --> 00:03:50.703 If you're not bagging the patient, you're not going to see sliding. 00:03:50.703 --> 00:03:54.407 So, the technique is to try to find something that looks like this. 00:03:54.407 --> 00:03:59.679 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. 00:03:59.679 --> 00:04:02.010 Where there is a rib shadow here, and a rib shadow here... 00:04:02.010 --> 00:04:06.560 and then, there's the pleural line, but there's no sliding along the pleural line. 00:04:06.560 --> 00:04:11.391 So I want you to do is, you'll want to look on both the right and left side. 00:04:11.391 --> 00:04:18.680 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. 00:04:18.680 --> 00:04:23.370 Here were looking at the patient's right side and you see sliding. 00:04:23.401 --> 00:04:26.542 But then we look at the left side and we don't see any sliding at all. 00:04:26.542 --> 00:04:28.317 That tells us that we're right mainstemmed. 00:04:28.317 --> 00:04:30.888 And then what Scott's saying is that you pull back until you see sliding on both sides. 00:04:30.888 --> 00:04:33.132 Like this... 00:04:33.132 --> 00:04:38.808 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. 00:04:38.808 --> 00:04:41.330 So we know that we are no longer right mainstemmed. 00:04:41.330 --> 00:04:46.513 And then Scott's saying you just pull back an additional 3cm, and that way you know you're in an adequate place. 00:04:46.513 --> 00:04:49.159 And this really makes sense. 00:04:49.159 --> 00:04:53.570 This is physiology, this is really basic ultrasound understanding. 00:04:53.570 --> 00:04:58.669 If we're aerating that lung, we're going to get sliding along that pleural line. 00:04:58.669 --> 00:05:01.526 This is a great tip, and really like the real-timeness of it. 00:05:01.526 --> 00:05:03.749 Yes...timeness is a word (at least in Kentucky). 00:05:03.749 --> 00:05:08.788 Personally, I use this more as confirmation, rather than real time visualization. 00:05:08.788 --> 00:05:13.511 I look at sliding while everyone else is auscultating after the intubation. 00:05:13.511 --> 00:05:22.015 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. 00:05:22.015 --> 00:05:26.810 And it only disappears after intubation, when you mainstem it and isolate that lung. 00:05:26.810 --> 00:05:34.124 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. 00:05:34.124 --> 00:05:36.438 Then it's probably a pneumo. 00:05:36.438 --> 00:05:39.260 Avoid this by looking prior to placement, while bagging. 00:05:39.260 --> 00:05:42.283 Now...did Weingart totally make this up? 00:05:42.283 --> 00:05:44.711 No, there's some pretty good evidence for using it. 00:05:44.711 --> 00:05:48.800 Just like any good ultrasound idea than anyone ever has, Blaivas has already studied it. 00:05:48.800 --> 00:05:56.304 In this study, he intubated a bunch of cadavers with a couple of other guys, and watched for lung sliding after the intubation. 00:05:56.304 --> 00:05:59.456 To confirm whether he was in the esophagus or trachea. 00:05:59.456 --> 00:06:02.611 And here are the results. 00:06:02.611 --> 00:06:04.697 Pretty awesome.. 00:06:04.697 --> 00:06:09.343 There were two different operators, one was 95% sensitive and the other was 100%. 00:06:09.343 --> 00:06:12.805 And they were both 100% specific. 00:06:12.805 --> 00:06:15.503 For telling whether the tube went in the trachea or esophagus. 00:06:15.503 --> 00:06:20.377 Now Scott was talking about position, as to whether or not it was right mainstemmed or not... 00:06:20.377 --> 00:06:22.538 And they looked at that as well... 00:06:22.538 --> 00:06:24.150 It turns out it, that's not quite as good. 00:06:24.150 --> 00:06:28.256 As you can see here - their sensitivity was quite a bit lower... 00:06:28.256 --> 00:06:31.520 So not as good at telling if its in the esophagus or trachea. 00:06:31.520 --> 00:06:34.142 Here's another study, more recent from resuscitation... 00:06:34.142 --> 00:06:37.254 Where they had somewhat better results in trying to identify single-lung intubations. 00:06:37.254 --> 00:06:43.681 They looked at these patients bilaterally, at the mid-axillary line after intubation, and their accuracy was 88.7% for identifying single lung intubation. 00:06:43.681 --> 00:06:45.879 Pretty good. 00:06:45.879 --> 00:06:47.006 Not perfect. 00:06:47.006 --> 00:06:49.244 So it's hard to say this is a sure thing, like the trachea versus esophagus. 00:06:49.244 --> 00:06:50.872 But not bad. 00:06:50.872 --> 00:06:55.216 And the had less than 10 total patients they got single lung intubated. 00:06:55.216 --> 00:06:59.440 So, I'm not sure what to make of the 88%. 00:06:59.440 --> 00:07:02.457 But it's something for you to think about. 00:07:02.457 --> 00:07:08.100 And just to be clear about what doesn't work, you can't use diaphragm movement, like this study tried. 00:07:08.100 --> 00:07:13.323 Specificity for mainstem intubation was 50% in this study. 00:07:13.323 --> 00:07:14.459 So don't do this. 00:07:14.459 --> 00:07:17.411 They did comment that it was 8minutes quicker than xray. 00:07:17.411 --> 00:07:18.580 But it was wrong. 00:07:18.580 --> 00:07:24.889 Sliding is better, like in the Blaivas study, but still not great for mainstem or not. 00:07:24.889 --> 00:07:30.308 So, this really hasn't been confirmed and shown that we're good enough at telling if it was mainstemmed or not. 00:07:30.308 --> 00:07:38.337 But I couldn't find anyone who's actually done the real time (watching the sliding) while advancing - that Weingart proposed. 00:07:38.337 --> 00:07:39.593 That would be really cool to see. 00:07:39.593 --> 00:07:43.418 These were static measures that I just showed you the studies for. 00:07:43.418 --> 00:07:47.332 A dynamic measure like that, may actually be useful and really good. 00:07:47.332 --> 00:07:50.552 I think someone should actually study this Weingart method. 00:07:50.552 --> 00:07:54.027 So I had also mentioned viewing the balloon in the cords. 00:07:54.027 --> 00:07:56.673 This looks like this - and is also useful. 00:07:56.673 --> 00:08:03.216 But if you are confirming after intubation, I think that good lung sliding while bagging the tube is much easier. 00:08:03.216 --> 00:08:07.528 And we've got great evidence for that, to tell whether or not it is in the esophagus or trachea. 00:08:07.528 --> 00:08:14.003 What is super useful and fun, is real time visualization of the tube placement. 00:08:14.003 --> 00:08:15.118 This is really cool. 00:08:15.118 --> 00:08:21.903 Now, like many others of you out there, I primarily use the glidescope, and have my residents use it as well. 00:08:21.903 --> 00:08:25.625 As you've got higher success rates, and less cranking on the person. 00:08:25.625 --> 00:08:26.816 i.e. better care... 00:08:26.816 --> 00:08:29.553 It's how I would want myself, or my family intubated. 00:08:29.553 --> 00:08:36.562 And when we use the video laryngoscope, I can watch, exactly what's going on, on the video - in real time. 00:08:36.562 --> 00:08:43.680 However, residents and new trainees need to be able to use the normal blade. 00:08:43.680 --> 00:08:47.417 So for newer intubators, I will have them try direct laryngoscopy first with glidescope next to us - ready as needed. 00:08:47.417 --> 00:08:56.394 And this use to be a somewhat nerve-wracking experience, as they are new users and I can't really see what is happening. 00:08:56.394 --> 00:09:03.203 It always amazed me how of then they could definitely see the cords if I asked, but it ended up in the goose somehow. 00:09:03.203 --> 00:09:08.755 Now I know I could have them use the glidescope as a direct laryngoscope, and only look at the screen myself. 00:09:08.755 --> 00:09:14.120 But I think they should get comfortable with actual steel. 00:09:14.120 --> 00:09:18.098 It definitely makes me less comfortable though when I am teaching them this way. 00:09:18.098 --> 00:09:20.329 Since I can't see what's going on. 00:09:20.329 --> 00:09:23.374 But super nerve-wracking no more! 00:09:23.374 --> 00:09:27.481 Now I just quietly, relaxed, place the probe on the neck. 00:09:27.481 --> 00:09:32.079 And get this picture of the trachea, and the esophagus. 00:09:32.079 --> 00:09:35.358 Then I ask them, "what do you see?" 00:09:35.358 --> 00:09:37.567 ughhhh......I think I see the cord, I'm passing through the cord. 00:09:37.567 --> 00:09:48.210 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). 00:09:48.210 --> 00:09:50.205 So then they pull back just a bit, and try again. 00:09:50.205 --> 00:09:55.003 And then I see this. 00:09:55.003 --> 00:09:55.905 The espophagus, the trachea. 00:09:55.905 --> 00:10:01.113 And as the tube passes through the trachea, I see it light up. Just like that. 00:10:01.113 --> 00:10:05.118 And then I know it was definitely through the cords. 00:10:05.118 --> 00:10:10.864 They ask me "How do the lungs sound?", and I say "Don't worry about it, I trust ya"...and then I walk away. 00:10:10.864 --> 00:10:12.603 Not really...I wish I was that cool. 00:10:12.603 --> 00:10:15.235 I'm actually still sweating it, and waiting for the CO2 monitor to turn yellow. 00:10:15.235 --> 00:10:16.714 Listening to both side, and looking for sliding. 00:10:16.714 --> 00:10:20.139 But I'm trying to do it all while looking somewhat cool. 00:10:20.139 --> 00:10:22.474 I definitely have a reputation to look after. 00:10:22.474 --> 00:10:25.186 And again, I'm not totally making this up. 00:10:25.186 --> 00:10:27.417 It's been studied a fair amount. 00:10:27.417 --> 00:10:34.248 In this study, they had EM doctors watch the neck sonographically during real intubation in the OR with elective surgery. 00:10:34.248 --> 00:10:37.146 And these guys were pretty awesome. 00:10:37.146 --> 00:10:44.351 But is it true that you could do this in the ED (Not in elective intubation)? 00:10:44.351 --> 00:10:49.846 Well, this other group studied this in the tracheo-rapid US exam or TRUE study. 00:10:49.846 --> 00:10:52.129 And they too were awesome. 00:10:52.129 --> 00:10:58.462 Prospective, real ED intubations, 98.2% accuracy! 00:10:58.462 --> 00:11:03.303 So, what doesn't work for looking at the neck for tube placement? 00:11:03.303 --> 00:11:06.860 Well, you can't really look after the fact. 00:11:06.860 --> 00:11:15.586 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. 00:11:15.586 --> 00:11:22.337 But what this study found, was that the sensitivity fell to 51% (From 97%) in the same intubations. 00:11:22.337 --> 00:11:25.671 When compared to the dynamic view. 00:11:25.671 --> 00:11:27.356 Watching it in real time. 00:11:27.356 --> 00:11:30.708 You have to watch it while it's happening, not afterwards. 00:11:30.708 --> 00:11:35.478 And if you're feeling really frisky....you don't have to do these things in isolation, you can combo-them up. 00:11:35.478 --> 00:11:38.836 Watch the neck, watch for sliding bilaterally. 00:11:38.836 --> 00:11:44.299 It's all information you can put together in your overall assessment. 00:11:44.299 --> 00:11:49.045 So, a real quick how-to and logistic discussion. 00:11:49.045 --> 00:11:52.090 First, it's at the suprasternal notch. 00:11:52.090 --> 00:11:56.095 Much lower than what you're probably expecting. 00:11:56.095 --> 00:12:00.035 Not at the cricothyroid membrane, but lower to get this view. 00:12:00.035 --> 00:12:05.326 I prefer the curvilinear probe, with the depth adjusted as shallow as it could go. 00:12:05.326 --> 00:12:09.064 And as you can see I have the probe here on Mike's neck, midline. 00:12:09.064 --> 00:12:13.680 And you can't really see the esophagus because it is hidden behind the trachea. 00:12:13.680 --> 00:12:17.491 Mike's swallowing here, but you don't really see it because it is behind the air-filled trachea. 00:12:17.491 --> 00:12:22.030 However, if you move the probe to the side, kind of oblique. 00:12:22.030 --> 00:12:24.807 Just as you see on Mike's neck here. 00:12:24.807 --> 00:12:27.494 You can definitely see the esophagus, right beside the trachea. 00:12:27.494 --> 00:12:32.962 And as he swallows, I think he was drinking a skinny sugar-free banana latte with extra whip cream. 00:12:32.962 --> 00:12:36.466 It's super easy to see that esophagus slide out. 00:12:36.466 --> 00:12:40.326 Just like you can see it light up as you passed the air filled tube through it. 00:12:40.326 --> 00:12:44.832 Hopefully not, but if you're resident or someone else did. 00:12:44.832 --> 00:12:47.597 If you're showing a video it's always the resident, it's not you. 00:12:47.597 --> 00:12:51.389 Now, you probably want a protocol, right? 00:12:51.389 --> 00:12:54.724 Well, too bad. 00:12:54.724 --> 00:12:56.339 I'm not interested in giving you a protocol for this. 00:12:56.339 --> 00:12:59.754 What I want is to give you mad skillz. 00:12:59.754 --> 00:13:05.879 Take all this, practice on yourself, you're going to be amazed at how easy it is to see the esophagus and trachea. 00:13:05.879 --> 00:13:08.390 Practice on some cadavers. 00:13:08.390 --> 00:13:11.294 And try it out in some non-emergent conditions first. 00:13:11.294 --> 00:13:14.284 Then go for it. 00:13:14.284 --> 00:13:17.080 Use what you need, when you need it. 00:13:17.080 --> 00:13:19.608 Obviously this does not replace capnography, xray, and other means of confirmation. 00:13:19.608 --> 00:13:22.664 But it's one more piece of data in real time. 00:13:22.664 --> 00:13:24.770 Sometimes, very helpful. 00:13:24.770 --> 00:13:32.598 Sometimes knowing 30s sooner than you would with capnography is really important for a sick, desating patient. 00:13:32.598 --> 00:13:34.784 So, I like it! 00:13:34.784 --> 00:13:37.021 And I think Mikey likes it too. 00:13:37.021 --> 00:13:38.219 Right Mike? 00:13:38.219 --> 00:13:41.478 Mike: I couldn't agree more Matt, this is really interesting stuff. 00:13:41.478 --> 00:13:46.031 And I think the most interesting aspect of this is using the dynamic US. 00:13:46.031 --> 00:13:52.817 To really ensure that the resident or whoever the provider is, really has the tube in the right place. 00:13:52.817 --> 00:13:58.920 Because, I think it is ridiculously easy to tell whether it is going into the esophagus or trachea. 00:13:58.920 --> 00:14:03.630 As far as what Scott's talking about - using US for placement of the tube. 00:14:03.630 --> 00:14:07.384 And determining whether you've got a right or left mainstem. 00:14:07.384 --> 00:14:11.292 I think that's really interest, and their isn't a lot of research on that. 00:14:11.292 --> 00:14:15.125 But I did find a case series. 00:14:15.125 --> 00:14:17.241 Reported by none other than Mike Blaivas. 00:14:17.241 --> 00:14:23.689 Looking at POCUS for sonographic detection of ETT mainstem intubation. 00:14:23.689 --> 00:14:30.659 This is really interesting because, these were just unusual cases, where they found the ETT went into the left mainstem. 00:14:30.659 --> 00:14:36.058 Basically lost lung sliding on the right when they looked with US after intubation. 00:14:36.058 --> 00:14:38.918 And they looked because they had decreased breath sounds on the right side. 00:14:38.918 --> 00:14:43.814 And what they ended up doing in most of these cases was pulling the tube back 2-3cm. 00:14:43.814 --> 00:14:47.691 So you should check it out, it's in the Journal of US. 00:14:47.691 --> 00:14:51.400 And pretty cool stuff. 00:14:51.400 --> 00:14:53.757 Matt: I've got 2 important pieces of new for you. 00:14:53.757 --> 00:14:58.231 1) If you've made it this far we've got bonus clip for you from Casey Parker at broomedocs.com. 00:14:58.231 --> 00:15:03.366 2) You can quit emailing me about finding a replacement for Mike because I found him. 00:15:03.366 --> 00:15:06.753 You already know that Casey is brilliant, from reading posts on his broomedocs blog. 00:15:06.753 --> 00:15:12.296 2 days ago he sent me this clip from the chapter he's writing for Introduction to Bedside US Volume 2. 00:15:12.296 --> 00:15:16.324 On the Secondary US Survey in Trauma. 00:15:16.324 --> 00:15:18.554 It's related to this topic, so I wanted to throw it in here. 00:15:18.554 --> 00:15:22.719 Now the stethoscope can still be a very useful tool in this process. 00:15:22.719 --> 00:15:24.971 He's brilliant, hilarious and Australian. 00:15:24.971 --> 00:15:32.313 You're in a busy trauma and your resident's just intubated the patient. 00:15:32.313 --> 00:15:36.351 And the sats are really staying in the low 90s. 00:15:36.351 --> 00:15:39.819 Pressure alarm on the ventilator is going off. 00:15:39.819 --> 00:15:42.552 You realize that something's not quite right. 00:15:42.552 --> 00:15:46.481 So you pick up your linear probe and place it on the left chest wall. 00:15:46.481 --> 00:15:49.827 And you look at what's going on there. 00:15:49.827 --> 00:15:53.753 At first glance, it looks like normal lung sliding. 00:15:53.753 --> 00:15:58.903 But if you look closely, and listen to the sats monitor in the background. 00:15:58.903 --> 00:16:03.320 Beep.Beep.Beep.Beep.Beep.Beep.Beep. 00:16:03.320 --> 00:16:07.688 You'll notice these movements are time exactly with the cardiac pulsations. 00:16:07.688 --> 00:16:09.700 This is the lung pulse-sign. 00:16:09.700 --> 00:16:14.233 Of a normally expanded, but non-ventilated lung. 00:16:14.233 --> 00:16:19.546 Most likely a right mainstem bronchus. 00:16:19.546 --> 00:16:23.494 And you'll want to pull that tube back, so you can once again ventilate that lung. 00:16:23.494 --> 00:16:29.013 At this point, you should leave the probe on the chest wall, while you withdraw the tube. 00:16:29.013 --> 00:16:33.808 And you can confirm sliding once you've pulled the tube back past the carina. 00:16:33.808 --> 00:16:37.290 I usually get my stethoscope at this point. 00:16:37.290 --> 00:16:39.306 And use it to strangle the resident. 00:16:39.306 --> 00:16:43.121 That way everyone learns something from the experience.