Written by Chris Thom
Spoon Feed
This meta-analysis demonstrated that POCUS for pediatric ETT confirmation is highly sensitive, moderately specific and can be efficiently performed at the bedside.
POCUS aids in ETT confirmation
Ten studies that evaluated POCUS for pediatric (age < 18) ETT confirmation were included in this meta-analysis. Studies selected were those that took place in the acute care environment (e.g. – ED, ICU, OR). The primary outcome was diagnostic accuracy of POCUS in detecting ETT misplacement, with secondary outcomes including time to ETT confirmation, re-intubation rates, and POCUS-related complications.
There were 697 pediatric patients analyzed within these 10 studies. The pooled sensitivity of POCUS for confirming ETT placement was 95% (95%CI 88-98), specificity 70% (95%CI 34-92). The average time for POCUS ETT confirmation was 45.8 seconds (95%CI 1.02-90.58). The procedural success rate for obtaining adequate POCUS views was 97%.
How will this change my practice?
Airway ultrasound has always struck me as an interesting niche. With how good ETCO2 is, we often don’t need this additional adjunct, and it does require a reasonable degree of operator experience to do it correctly. However, once ETCO2 is absent or unreliable (e.g. – certain cardiac arrest scenarios), airway ultrasound suddenly becomes the best tool available for ETT confirmation. Given this, I’ve tried to keep these skills sharp, as they can be needed in the occasional critical airway case. The current study showed excellent sensitivity but only moderate specificity, which means there is a risk of thinking there is esophageal intubation despite correct ETT placement.
POCUS pro-tips and clips
The trachea is easy to identify with a bit of practice. Place the linear transducer over the midline neck at around the level of the cricoid cartilage or just above the suprasternal notch. You’ll have the ultrasound in place in this area during the actual ETT placement (e.g. – a second operator is needed to do the POCUS during the intubation). The trachea will be easy to identify given its echogenic, air interface and semi-circular appearance. If the ETT goes into the esophagus, you will see a second circular air interface appear on the screen, generally on the left side given the anatomy of the esophagus. If the ETT goes into the trachea, you will generally see no change under POCUS imaging, albeit occasionally one can detect a small shimmer or additional reverberation within the trachea.
Source
Diagnostic accuracy of point-of-care ultrasound for confirming endotracheal tube placement in pediatric acute care settings: a systematic review and meta-analysis. BMC Emerg Med. 2025 Dec 22;25(1):261. doi: 10.1186/s12873-025-01455-x. PMID: 41430150; PMCID: PMC12752094.
