In the last post Intubation Confirmation, you stated that we should not trust our eyes.
Not when other confirmation methods suggest that the tube is in the wrong place.
And I suppose not using other tube confirmation methods is a bad idea.
Beyond bad.
So, what should we trust?
There is no one perfect assessment to trust. Multiple methods should be used to confirm placement.
Such as?
Lung sounds.
Of course, that is the most important assessment.
No, belly sounds are more important.
Why?
We are looking for any sign that the tube is in the wrong place. Lung sounds do not provide that information. Lung sounds may be referred, or absent, or ambiguous, or . . . , they are not good at telling you the tube is in the esophagus.
But we want to know that the tube is in the trachea.
It is more important to know if the tube is in the esophagus.
Why?
The esophagus is a route to the stomach contents. The stomach is expected to be full of all sorts of yucky foods that are not good for the lungs. The stomach also contains hydrochloric acid. Lung tissue is delicate and does not respond well to a hydrochloric acid challenge.
So it is better to avoid filling the stomach with air that will act as a propellant and fill the airway with food and acid and other nastiness.
Also, there is great entertainment value in watching the way people listen to lung sounds. First they listen to one lung for a while, then they listen to the other lung for a while, then they go back to the first lung . . . .
As if listening longer is going to encourage the tube to move to a more acoustic spot.
Precisely, and the stomach is just becoming more and more distended during this time of self deception.
So you listen to the stomach first?
I don’t. You don’t really expect me to be like everyone else, do you?
Not even in assessing tube placement. Oh, well.
I place my hand over the stomach and both lungs at the same time. Sound causes vibration that can be felt with the hands, called tactile fremitus. This allows me to assess all three locations simultaneously and makes it easier to differentiate among referred sounds.
That must take practice.
What assessment method doesn’t?
OK. I suppose it helps to have big paws.
Woof. One of the reasons I do this is too find out as quickly as possible where the tube is, because each squeeze of the bag places about half a liter of gas into the patient.
So, if this gas is going into the stomach, the stomach is going to fill up in just a few breaths.
Yes, it is. Sometimes, just one breath.
And something that fills up quickly can empty quickly?
Quickly, perhaps violently, but in a way that distracts everyone from airway management.
Then you’d better tell about other assessments tube placement, because nobody likes being vomited on.
Emetophiliacs might.
Eww!
Another method of assessment is to look for belly rise.
That means that the tube is in the wrong place.
No. Normal diaphragm movement will result in pressure on the intestines and stomach and some belly rise. That belly rise should return to the same level at the end of exhalation, if the tube is in the trachea. If the tube is in the esophagus, the belly rise may decrease with exhalation, but will probably not return to its original dimensions. Some distension will usually remain. And if the patient starts vomiting through the tube that is usually a pretty big clue about tube position.
You want to pull that tube pretty quickly.
No. The tube is helping to protect the airway if the stomach contents are coming out of the tube, instead of ending up in the airway. When attempting to place another tube it can guide you to the trachea, which should be higher than the tube already in place.
Then you pull the other tube after you have confirmed that the new one is in the trachea.
Still, no. The tube is directing the stomach contents to a safer place, at least for the patient, not necessarily for the bystanders. So, try not to direct this at any of your coworkers. You can mess with them later, when you are not trying to manage an airway.
It is good that we covered all of these confirmation methods.
No, we aren’t even half way there.
More posts to come?
Of course.
Other posts about this:
RSI Problems – What Oversight?
RSI, Intubation, Medical Direction, and Lawyers.
RSI, Risk Management, and Rocket Science
.
[…] More Intubation Confirmation […]