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Five Parameters to Determine Proper Tube Placement

EMS providers need to have proof — not just a hunch — that their endotracheal tube is correctly placed. The following parameters can help providers ensure their tube isn’t in the esophagus.

1. Direct visualization
2. Tube depth measurement
3. Presence or lack of epigastric sounds
4. Breath sound confirmation
5. Chest expansion visualization

Get more specifics on these parameters and learn how they are part of the art of post-intubation management in “Life of the Tube.”


  1. While I fully agree that EMS providers need proof that the ETT has been placed succesfully, I do not agree with most the parameters provided. Direct visualisation has been, and still is, considered to be the gold standard for confirmation. Tube depth proves the same thing as a chest x-ray: you didn’t push it down too far, but too far down what? The esophagus or the trachea? Presence or lack of epigastric sounds is not definitive as an empty stomach may not give such sounds and breath sounds and chest expansion are of questionable value in the spontaneously breathing patient. I am currently attending an airway certification program as part of my further studies as a South African Paramedic and ETT placement confirmation was something we spent some time discussing. Most important to note is that no one single parameter should be relied on due to false positives, which are possible with any parameter. However, the most reliable parameters are: direct visualisation, negative finding for an esophogeal detector device and waveform capnography. In addition, auscaltation of epigastric and bilateral axillae regions is also used. Capnography is catching on here in the EMS due to the increasing use of monitors such as the LifePack 15 in the prehospital setting, to the point where I use it on almost every ALS patient. Just some food for thought.

  2. The acronym C.L.E.A.N.E.D. may be helpful in determining proper tube placement.
    C. CO2 detection (colorimetric device or capnography/capnometry)
    L. Lung sounds/compliance
    E. Expansion of chest
    A. Absence of epigastric sounds
    N. Numeric tube depth
    E. Esophageal intubation detection device
    D. Distention of abdomen

  3. In my neck of the woods, ETCO2 is the gold standard in tube placement confirmation. I have no problem blindly going for a tube with the help of waveform ETCO2. After I have a waveform and a etco2 value its just lung souds to verify im not in too far. Makes it easy to print a waveform strip hand it to the doc and say…..the tube is good.

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