You have devoted a considerable amount of time and energy in training to be comfortable in airway management. As part of the care of the intubated patient, you want to make sure the endotracheal tube is correctly placed in the trachea and your patient’s airway is secure.

Verification of endotracheal tube placement is imperative for the oxygenation, ventilation, and airway protection of your patient. A tube in the esophagus, or in the hypopharyngeal space, may be incorrectly thought to be in position and may place your patient at undue risk of hypoxemia or aspiration.

Therefore, confirmation of proper endotracheal tube placement should be completed in all patients at the time of initial intubation. Unfortunately, at this time no technique used for confirmation of endotracheal tube placement has been proven to be 100% accurate.^1-7

A variety of techniques may enhance your ability to confirm airway placement; comfort with these techniques is essential to your practice.

Visualization of the endotracheal tube passing through the vocal cords remains the optimal method for initial endotracheal tube placement. Unfor-tunately, direct visualization is not always possible, especially in the anatomically difficult airway or an airway that is obscured by blood, secretions, or vomitus.

Other physical examination methods such as auscultation of the lungs and epigastrium, visualization of bilateral chest rise, and fogging of the tube may be helpful but are not sufficiently reliable to confirm placement of the tube between the vocal cords.

What makes confirmation even more difficult is that esophageal intubation may remain undetected despite chest radiography and pulse oximetry results that appear to confirm proper tube placement.^1-7

These methods cannot exclude esophageal intubation in all situations, and for this reason, additional methods should be used to verify correct initial placement of the endotracheal tube.

Techniques to Confirm Tube Placement

To supplement traditional methods, a variety of additional techniques and commercially available products help to identify misplaced tubes.

These include repeat direct laryngoscopy, qualitative and quantitative end-tidal carbon dioxide detection, esophageal detector devices, and, most recently, ultrasound, and transthoracic impedance.^8-21