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And Why Do We Use Multiple Methods To Confirm Tube Placement?

This is why, boys and girls.

Breath sounds alone are not sufficient, nor is the presence of breath sounds over the epigastrum sufficient reason to pull the tube.

Presence of gurgling over the epigastrum is another story. Actual breath sounds can resonate through the diaphragm to be heard in the stomach, and gastric sounds can be heard vice versa. The best way to confirm tube placement is to use every method at our disposal, with at least one of those methods being waveform capnography.

In this case, a gaggle of physicians even ignored an awful set of arterial blood gases at first, and chose to tweak ventilator settings instead. The chest radiograph eventually told the tale, but even a chest x-ray can be fooled. Remember, the chest radiograph shows the depth of the tube. It may be at the optimum depth on the chest film… but in the esophagus and not the trachea.

One of the biggest lies in EMS is "I swear I saw the tube go through the cords."  Think about it: when is it ever necessary to even speak those words, unless the tube has proven to be in the wrong place?

The only self-delusions to rival it in EMS are "Looks like atrial fib" and "I think the triage nurse has the hots for me."

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Comments - Add Yours

  • http://www.facebook.com/people/John-Gaines/607557710 John Gaines

    It does amaze me, in this day and age, that some supposed “professionals” are to close minded and/or cocky to think that they don’t need a standard checklist of methods to follow to confirm placement of a tube. If checklists are good enough for surgeons and pilots, why do we fight against them?

    • Christopher

      I believe that case report is from 1983, not that it necessarily excuses things. As I was born that year I can’t speak to the ready availability of capnography, whether waveform or quantitative.

      • Ambulance_Driver

        Still a good teaching case for multiple confirmation methods, though.

        • Christopher

          This is most certainly a textbook case for why you have to assume you didn’t get it at first. Personally, I would have liked to have seen them use the clown nose confirmation device.

          • Ambulance_Driver

            Of course, the clown nose is only reliable (and not very) if you use it before you check breath sounds or before anyone has provided any bystander ventilation.

      • http://roguemedic.com/ Rogue Medic

        Yes, it is from before waveform capnography was available, and even before color change detectors were available.

        The point is that their assessment was inadequate.

        This is not something that has changed with waveform capnography.

        There are still people who will make excuses for EtCO2 that is not consistent with a properly placed tube, rather than use other assessment methods.

        Even waveform capnography is not perfect and should be used as only a part of the assessment of tube placement.

        I listen to the stomach first, because lunch may arrive before the waveform capnography makes the tube’s position clear.

        I don’t need to see, smell, touch, or taste the patient’s lunch. Hearing it is enough. ;-)

        .

        • Christopher

          Agreed on all points, except I think with the advent of readily available waveform ETCO2 you no longer have an excuse…

  • http://roguemedic.com/ Rogue Medic

    Thank you for the link.

    The original X-ray was misinterpreted by the doctors. That is one of the reasons they were able to tell that the tube had been in the esophagus for so long.

    Considering that insanity may be a prerequisite to be a triage nurse, she just might have the hots for me. O-o

    .

  • Ted

    I’m a big fan of repeat visualization. Take another look: is the tube where you left it? There’s also the Eschmann technique (if you can “hub” the Eschmann through the tube then you’re not hitting the carina). Add this information to the data from your EtCO2 and pulse oximeter and the chest x-ray becomes almost superfluous.