ARRS 2022 Abstracts

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1682. Alternate Protocol for Frontal Radiographs to Assess Endotracheal Tube Placement Improves the Confidence of Decision-Making
Authors * Denotes Presenting Author
  1. Rokas Liubauskas *; Beth Israel Deaconess Medical Center
  2. Diana Litmanovich; Beth Israel Deaconess Medical Center
  3. Ronald Eisenberg; Beth Israel Deaconess Medical Center
Objective:
Following intubation, a frontal chest radiograph (CXR) is obtained to assess endotracheal tube (ETT) position by measuring the distance between its tip and the carina. ETT tip location is influenced by neck position (up to 3.8 cm between full extension and flexion), so it is crucial to know the position of the neck, which can be done using mandible position as a landmark. Incorrect positioning of the ETT may lead to such complications as endobronchial intubation, pneumothorax, self-extubation, and vocal cord injury. We developed a new CXR acquisition protocol designed to include the mandible on post-intubation CXR and compared its accuracy in determining precise ETT position with the standard protocol.

Materials and Methods:
Following intubation, half of our patients had routine anteroposterior CXR and half had a new protocol, in which technologists were taught to include 1-2 cm of the distal mandible. If the mandible was visualized, we used literature data to determine neck position (neutral, flexed, or extended) based on mandible position relative to the vertebrae. If the mandible was not visualized, we used literature data to establish “gray-zone” values where potential neck movement would make it difficult for a radiologist to assess for proper ETT position. We also established “clear-zone” values where the radiologist can confidently recommend advancing, retracting, or leaving the ETT in the current position. Finally, we proposed a two-step process to confidently assess ETT position on CXR and make appropriate recommendations. We compared the confidence of decision-making when assessing the ETT position on CXR using the standard and the new protocols.

Results:
Of our 308 patients, 155 had the standard technique and 153 had the new protocol. There was a significant increase (p<0.001) in visualization of the mandible with the new protocol (92%; 141/153) compared to the standard technique (21%; 32/155). When the mandible was not visible, the ETT was in a gray zone in 60.9% (75/123) of CXR using the standard technique and in 41.7% (5/12) using the new protocol. Either by visualizing the mandible; or observing the ETT in the “clear-zone,” a radiologist could confidently assess the ETT position in 96.7% of cases using the new protocol versus only 51.6% with the standard technique (p<0.001).

Conclusion:
Mandible visibility on post-intubation CXR is critical for assessing ETT position. Our newly developed protocol resulted in a significant increase in both visualization of the mandible on post-intubation CXR and accuracy determining ETT position. It increased the confidence of decision-making from 51.6% to 96.7% and can prevent unnecessary imaging.