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Ways to Confirm Proper Endotracheal Tube Placement

In “Trauma Airway Intubation Is a Team Effort,” author Christopher T. Stephens, MD, MS, NREMT-P, stresses the importance of confirming proper endotracheal tube placement. He lists several ways this is done:

Chest rise;
Bilateral breath sounds;
Tube fogging;
Calorimetric end-tidal carbon dioxide; and
Continuous waveform capnography.

Continuous waveform capnography ideally should be used by every paramedic unit that’s intubating patients in the field. This will be discussed further in the next article, due out Feb. 8. Stay tuned for more!


  1. Well tube fogging is good unless you still get fogging when you intubate the wrong hole. Also, hard to assure waveform capnography when the company that supplies the equipment to let your phillips monitor this cannot even enter the country….yep, awesome.

  2. We just got waveform capnography, very excited about implementing it with my Pt’s whom are getting intubated!

  3. i dont not believe that waveform capnography is neccessary in the short term emergency prehospital environment due to other vital tasks that have to be completed on these critical patients with limited manpower available on the rig. Also visualization of passing the tube through the vocal cords was not mentioned as a confirmation technique which i think is probably the most important one of all with other methods used to confirm you successful intubation. on longer transport times and transfers to other facilities i can see waveform capnography being a beneficial tool for diagnostics and continued monitoring to prevent from hyper or hypo ventilation.

    • As you stated waveform capnography is a good tolls for longer transports and continueed monitoring that might get int he way of a short staffed crew. But remember, when diesigned simply, such as a device that sits on the tube between the tube and bag, and set simply on the monitor it is a sure confirmation of tube placement. Only thelungs will expel CO2, the gastric tract wil not.

      As long as there is a wave you must be in the trachea.

    • grmedic: If you look at the evidence for intubation, capnography is considered a Class 1 intervention per the AHA and “PETCO2 also provides indirect evidence of the quality of chest compressions” per AHA guidelines. It has risen to the level of “gold standard” for the ET skill and we may eventually see it rise to negligence for services that are not using it for a confirmation given it is a highly effective tool. Application of the pulse oximeter and end-tidal CO2 provides a 1-2 punch of feedback on the ET skill. Direct visualization of the tube entering the cords is certainly helpful, and by your response it sounds as if you have a fair bit of experience with intubation so I ask you- have you ever lost a tube that you watched enter the cords as you removed the blade from the mouth? How about when the patient was lifted from the floor to stretcher or log rolled on to a long board. I have seen this happen a few times and recall thinking “it can’t be dislodged, I SAW it go through the cords.” Of course (and I hope) we detected it and corrected it right away, but my point is, visualization is one of several steps and often does not even crack the top 10 of bullet proof confirmation techniques for me. I also have not noted attaching the ET capnography device to take any more time in the set-up and find the risk/benefit ratio in favor of doing it.

  4. In our Service, we us a PosiTube http://ps-med.com/products/detail.php?p=42

    I was shown how to make a similar device by an Anaesthetist when I first did my Paramedic training back in 1985. I used a 50ml catheter syringe (not Luer-lock) and a 90 degree catheter mount (a rubber one, in those days).

  5. In our Service, we use a PosiTube http://ps-med.com/products/detail.php?p=42

    I was shown how to make a similar device by an Anaesthetist when I first did my Paramedic training back in 1985. I used a 50ml catheter syringe (not Luer-lock) and a 90 degree catheter mount (a rubber one, in those days).

  6. While all of these are good suggestions, I recommend we always follow the AHA recommendation on proper tube placement. First a foremost, if we visualize, under direct laryngoscopy , passage of the tube trough the vocal cords and then confirm the ABSENCE of epigastric sounds, then the other assessment tools come into play. Calorimetric end-tidal carbon dioxide and
    Continuous waveform capnography are a helpful secondary tool of confirmation but, are not a substitute for the physical signs of proper tube placement.

    • Perhaps you’re putting too much emphasis on the “physical signs” as well.

      Some statistics from studies googled:

      Quantitative Capnography: Correctly confirmed ET tube placement in the trachea 97% of the time out of 2192 intubations.

      EDD (Esophageal Detection Device) bulb/syringe: Correctly confirmed 70.8% of endotracheal intubations. Correctly confirmed 100% of 8 esophageal intubations.

      Misting of the tube: In one study, misting of the tube was observed in 100% of 27 endotracheal intubations, and 83% of 27 mistaken esophageal intubations.

      Lung/Epigastric sounds: Correctly indicated endotracheal intubation 85% of the time in 40 endotracheal intubations in one study. Another found that it depended highly on examiner experience: Inexperienced examiners were only correct 68% of the time in determining tube placement.

      Visualization of the tube passing the cords: Depending on the study, anywhere from 1-3% of endotracheal intubations by skilled practioners in a hospital setting resulted in undetected esophageal intubation. I didn’t look a the prehospital stats, but I’m sure they’re higher.

      I think the take home message here is to use multiple methods and trust nothing independently.

  7. Anyone opposed to waveform capnography needs to think again, or take another look at it. We’ve been using it for over a year now and our directives require us to use it when available. In addition to confirming tube placement (it’s primary function) it has several other benefits.

    In addition to confirming the tube initially, it remains in place – still have a waveform, still have a tube. Just jostled the patient around a bit or tugged the tube slightly? Yep, depth still looks right… a quick look at the monitor confirming the proper waveform will confirm the tube is still in.

    It will often be the first sign of a ROSC, as reported by some of my colleagues. I’ve yet to experience this myself, but some of my peers in a neighboring service have had it for a while, and a sudden significant increase in ETCO2 often precedes other signs of a ROSC.

    It allows you to better titrate your oxygenation to achieve the target SPO2 and ETCO2 values.

    It can be used in the big picture to help determine whether further resuscitation is futile. If the ETCO2 remains very low following resuscitation and ACLS, the changes of subsequently obtaining a ROSC are very low.

    To anyone who says “I have other things to do than worry about the ETCO2”, it takes very little time to use. We use the Zoll M Series – the only important thing I would recommend it to remember to turn it on at the start of the arrest to warm up – ours stays disabled as it draws a lot of power and would drain the batteries too quickly in routine monitoring. It does take about two minutes to warm up – for us this isn’t a problem as we only have one ALS provider on scene and by the time the IV is established and drugs are going in it’s warmed up and ready for the intubation.

    Overall, I feel it’s a useful tool. It takes little time to use, little time to train, and is associated in studies with better recognition of correctly (and more importantly, incorrectly) placed tubes.

    • Notwithstanding physical checks for correct tube placement, capnography should be mandatory. It is the only system that provides accurate, first breath confirmation of tube placement, breath-by-breath confirmation of continued tube placement, early indication of ROSC, changes to airways (e.g. development of bronchospasm / gas trapping) and effectiveness of ventilation / CO2 control. In my service we apply the ETCO2 airway adaptor to the BVM during pre-oxygenation to confirm its working, and to signal apnoea when the sux is administered. It is then in place once intubation is acheived.

      Any service that is ventilating intubated patients, whether by hand or mechanically, is negligent in my opinion if they are not using ETCO2.

      Added bonus – it is great for monitoring respiratory rate and effort in the non-intubated, sedated, spontaneously breathing patient. Just attach sampling tube or ETT adaptor to side of O2 therapy mask and watch the monitor for waveform and resp rate. If the patient obstructs or hypoventilates you will pick it easier on the waveform than trying to visualise chest movement under a pile of blankets.

      However, it is of no use in directly assessing oxygenation, as per K’s comment above.

  8. Dr. Stephens,

    Please move continuous waveform capnography to the top of your list. When we make a “list” of ways to confirm placement and the only objective ways to confirm are at the bottom, we are sending the wrong message. Yes, chest rise and breath sounds are useful, but they are subjective assessments. Waveform capnography is the OBJECTIVE way of confirming tube placement. Period.
    Physician oversight and leadership, such as yourself, must reinforce this practice. Otherwise, ETCO2 falls to the bottom of the list and we’re lucky if it gets attached sometime in the truck on the way to the hospital.

  9. ETCO2 is EVIDENCE BASED PRACTICE. And what’s more most machines allow for a printout of a continuous waveform. Number one way to prove the tube is in is a nice printout of a waveform and regular readings of your ETCO2. No need to fight it and in fact it should be embraced prehospitally. If it’s good enough for anaesthetists it’s good enough for me

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