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Confirmation of Correct Tracheal Tube Placement

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest, needing/with an advanced airway during CPR in any setting  (P), does does use of devices (eg, waveform capnography, CO2 detection device, esophageal detector device, or tracheal ultrasound)  (I), compared with compared with not using devices  (C), change placement of the ET tube between the vocal cords and the carina, success of intubation (O)?
Consensus on Science:
Waveform Capnography For the important outcome of detection of correct placement of a tracheal tube during CPR, we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Silvestri 2005, 497) showing that the use of waveform capnography compared with no waveform capnography in 153 critically ill patients (51 with cardiac arrest) decreased the occurrence of unrecognized esophageal intubation on hospital arrival from 23% to 0% (OR, 29; 95% CI, 4–122). For the important outcome of detection of correct placement of a tracheal tube during CPR, we identified low-quality evidence (downgraded for serious risk of bias and imprecision) from 3 observational studies(Tanigawa 2000, 1432; Grmec 2002, 701; Takeda 2003, 153) with 401 patients and 1 randomized study(Tanigawa 2001, 375) including 48 patients that showed that the specificity for waveform capnography to detect correct tracheal placement was 100% (95% CI, 87%–100%). The sensitivity was 100% in 1 study(Grmec 2002, 701; Takeda 2003, 153) when waveform capnography was used in the prehospital setting immediately after intubation, and esophageal intubation was less common than the average (1.5%). The sensitivity was between 65% and 68% in the other 3 studies(Tanigawa 2000, 1432; Tanigawa 2001, 375; Takeda 2003, 153) when the device was used in OHCA patients after intubation in the emergency department (ED). The difference may be related to prolonged resuscitation with compromised or nonexistent pulmonary blood flow. Based on the pooled sensitivity/specificity from these studies and assumed esophageal intubation prevalence of 4.5%, the false-positive rate (FPR) of waveform capnography was 0% (95% CI, 0%–0.6%). Colorimetric CO2 Detection Devices For the important outcome of detection of correct placement of a tracheal tube during CPR, we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 7 observational studies(Anton 1991, 271; MacLeod 1991, 267; Ornato 1992, 518; Sanders 1994, 771; Hayden 1995, 499; Bozeman 1996, 595; Grmec 2002, 701) including 1119 patients that evaluated the diagnostic accuracy of colorimetric CO2 devices. The specificity was 97% (95% CI, 84%–99%), the sensitivity was 87% (95% CI, 85%–89%), and the FPR was 0.3% (95% CI, 0%–1%). Esophageal Detection Devices For the important outcome of detection of correct placement of a tracheal tube during CPR, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, inconsistency, and a strong suspicion of publication bias) from 4 observational studies(Oberly 1992, 317; Bozeman 1996, 595; Tanigawa 2000, 1432; Takeda 2003, 153) including 228 patients, low-quality evidence (downgraded for risk of bias and indirectness) from 1 randomized study(Tanigawa 2001, 375) including 48 patients, and very-low-quality evidence (downgraded for risk of bias, indirectness, inconsistency, and a strong suspicion of publication bias) from 1 observational study(Pelucio 1997, 563) including 168 patients that evaluated esophageal detection devices. The pooled specificity was 92% (95% CI, 84%–96%), the pooled sensitivity was 88% (95% CI, 84%–192%), and the FPR was 0.2% (95% CI, 0%–0.6%). Low-quality evidence (downgraded for risk of bias and suspected publication bias) from 1 observational study(Tanigawa 2001, 375) showed no statistically significant difference between the performance of a bulb (sensitivity 71%, specificity 100%)- and a syringe (sensitivity 73%, specificity 100%)-type esophageal detection devices in the detection of tracheal placement of a tracheal tube. Ultrasound for Tracheal Tube Detection For the important outcome of detection of correct placement of a tracheal tube during CPR, we identified low-quality evidence (downgraded for suspicion of publication bias and indirectness) from 3 observational studies(Chou 2011, 1279; Chou 2013, 1708; Zadel 2015, 1) including 254 patients in cardiac arrest that evaluated the use of ultrasound to detect tracheal tube placement. The pooled specificity was 90% (95% CI, 68%–98%), the sensitivity was 100% (95% CI, 98%–100%), and the FPR was 0.8% (95% CI, 0.2%–2.6%).
Treatment Recommendation:
We recommend using waveform capnography to confirm and continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment (strong recommendation, low-quality evidence). We recommend that if waveform capnography is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound in addition to clinical assessment is an alternative (strong recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making these strong recommendations, and despite the low-quality evidence, we place a high value on avoiding unrecognized esophageal intubation. The mean incidence of unrecognized esophageal intubation in cardiac arrest was 4.3% (range, 0%–14%) in the 11 studies we assessed. Unrecognized esophageal placement of an advanced airway is associated with a very high mortality. We, therefore, place value on recommending devices with a low FPR (ie, the device indicates tracheal placement but the tube is in the esophagus). In addition, waveform capnography is given a strong recommendation, because it may have other potential uses during CPR (eg, monitoring ventilation rate, assessing quality of CPR).
CoSTR Attachments:
FINAL 469.docx    

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