O2043: Diagnostic Accuracy of Point-of-care Ultrasound Compared to Standard-of-care Methods for Endotracheal Tube Placement in Neonates

Background: Point of care ultrasound (POCUS) is a useful tool to determine endotracheal tube (ETT) placement; however, few studies have compared it with standard methods of confirmation. We evaluated the diagnostic accuracy of POCUS and time to interpretation for correct identification of tracheal versus esophageal intubations compared to a composite of standard-of-care methods in neonates. To train neonatal providers in POCUS, we utilized a novel, low-cost ultrasound simulator (Figure 1).

Methods: A cross-sectional study was conducted in the Neonatal Intensive Care Unit (NICU) at Aga Khan University Hospital Karachi, Pakistan. All required intubations were performed as per NICU guidelines. The ETT placement was determined using standard-of-care methods (auscultation, colorimetric capnography, and chest X-ray) by a clinical team, and simultaneously by POCUS. The clinical team was blinded to the POCUS images. Timings were recorded for each method by independent study staff.

Results: A total of 348 neonates were enrolled in the study. More than half (58%) of intubations were in an emergency scenario. Using an expert as the reference standard, POCUS user interpretation showed 100% sensitivity and 94% specificity. We found a 99.4% agreement (Kappa: 0.96; p< 0.001) between the POCUS user and expert.

Diagnostic accuracy of POCUS compared with at least two standard-of-care methods demonstrated 99.7% sensitivity, 91% specificity, and 98.9% agreement (Kappa:0.93; p< 0.001). The median time required for POCUS interpretation was 3.0 (IQR 3.0 -4.0) seconds for tracheal intubation. The time recorded for auscultation and capnography was 6.0 (IQR 5.0 -7.0) and 3.0 (IQR 3.0-4.0) respectively (Table 1).

Conclusion: POCUS is a rapid and reliable method of identifying ETT placement in neonates. Our low-cost simulator is effective for training healthcare providers and has the potential to be used in other low- and middle-income countries. Early and correct identification of endotracheal tube position is critical to save lives and prevent mortality and morbidity.