Background: Accurate confirmation of endotracheal tube (ETT) placement is vital during anaesthesia and emergency airway management. Conventional auscultation has limited sensitivity, whereas point-of-care ultrasound (POCUS) has emerged as a promising alternative. Objective: To compare the diagnostic accuracy of POCUS and auscultation in confirming ETT placement. Methods: Ninety ASA I–II patients undergoing elective surgery under general anaesthesia were randomised into three groups (trachea, right main bronchus, left main bronchus). Independent blinded anaesthesiologists performed intubation, fibreoptic confirmation, auscultation, and ultrasound examinations. Diagnostic indices were calculated against fibreoptic bronchoscopy (gold standard). Results: Auscultation achieved sensitivity 68.8%, specificity 87.8%, and accuracy 84.7%. POCUS demonstrated sensitivity 92.5%, specificity 95.3%, and accuracy 94.7%. Haemodynamics and oxygen saturation remained stable, while EtCO₂ and airway pressures increased significantly with endobronchial intubations. Conclusion: POCUS is more accurate than auscultation for confirming ETT placement. It is a rapid, reliable, and non-invasive bedside tool with potential to complement or replace auscultation in clinical practice.
Endotracheal intubation is routinely performed in anaesthesia, intensive care, and emergency medicine. Misplacement of the ETT into the oesophagus or bronchus can cause hypoxemia, atelectasis, or barotrauma, making rapid confirmation essential. Auscultation has traditionally been recommended but is limited by poor sensitivity, especially in noisy environments or with inexperienced practitioners. Point-of-care ultrasound (POCUS) offers dynamic, real-time airway assessment, with early studies suggesting high diagnostic accuracy. This study compared the diagnostic performance of POCUS and auscultation against fiberoptic bronchoscopy for confirming ETT position.
Design: Prospective, double-blinded, randomized controlled trial
Setting: Tertiary care hospital, Dehradun, India
Sample: 90 ASA I–II adult patients (20–60 years), elective surgeries under general anaesthesia
Exclusion: Obesity, lung disease, difficult airway, pregnancy, or refusal to consent
Procedure: Patients randomized into three groups (ETT in trachea, right main bronchus, left main bronchus). Fiberoptic confirmation served as gold standard. Five-point auscultation performed by blinded anaesthesiologist. POCUS examination (tracheal dilation and pleural sliding signs) performed by another blinded anaesthesiologist.
Outcomes: Diagnostic accuracy of each method. Secondary outcomes included haemodynamics, EtCO₂, and peak airway pressures.
Statistical Analysis: Chi-square/Fisher’s exact test, unpaired t-test, sensitivity/specificity/PPV/NPV, Kappa statistics. p < 0.05 considered significant.
Table .1 Changes in EtCO₂ and Peak Airway Pressure Pre vs Post Intubation
|
Parameter |
Tracheal Group |
Right Main Bronchus Group |
Left Main Bronchus Group |
p-value |
|
EtCO₂ (mmHg, mean ± SD) |
35.2 ± 4.1 |
44.5 ± 5.2 |
45.1 ± 4.8 |
<0.001 |
|
Airway Pressure (cmH₂O) |
18.3 ± 2.5 |
28.7 ± 3.2 |
29.1 ± 3.5 |
<0.001 |
Table 2. Diagnostic Accuracy of Auscultation vs POCUS Compared with Fibreoptic Bronchoscopy
|
Method |
Sensitivity (%) |
Specificity (%) |
Accuracy (%) |
PPV (%) |
NPV (%) |
Kappa (κ) |
|
Auscultation |
68.8 |
87.8 |
84.7 |
78.3 |
82.1 |
0.62 |
|
POCUS |
92.5 |
95.3 |
94.7 |
93.8 |
94.1 |
0.89 |
Table 3. Baseline Demographic and Clinical Characteristics of Patients (n = 90)
|
Variable |
Tracheal Group (n=30) |
Right Main Bronchus Group (n=30) |
Left Main Bronchus Group (n=30) |
p-value |
|
Age (years, mean ± SD) |
38.2 ± 10.5 |
39.1 ± 9.8 |
37.4 ± 11.2 |
0.72 |
|
Gender (M/F) |
18/12 |
20/10 |
19/11 |
0.83 |
|
ASA I/II (%) |
70/30 |
66/34 |
72/28 |
0.89 |
|
Weight (kg, mean ± SD) |
62.4 ± 8.7 |
61.9 ± 9.3 |
63.1 ± 7.9 |
0.91 |
Figure 1: Diagnostic performance of auscultation vs ultrasound (POCUS).
Figure 1: Diagnostic performance of auscultation vs ultrasound (POCUS).
Figure 2: Change in EtCO₂ pre vs post intubation.
Figure 3: Change in peak airway pressure pre vs post intubation.
This study confirms that POCUS significantly outperforms auscultation in detecting ETT placement, aligning with previous literature. Auscultation, although widely practised, is limited by poor sensitivity and dependence on operator expertise. In contrast, POCUS allows real-time airway assessment, is unaffected by environmental noise, and does not require interruption of chest compressions during CPR. The PLUS examination (tracheal dilation and pleural sliding) achieved high diagnostic accuracy (94.7%), supporting its role in routine airway confirmation. Limitations include the single-centre design and exclusion of obese and emergency cases. Further multicentre trials are warranted to validate its utility in critical and prehospital scenarios.
POCUS provides a rapid, reliable, and accurate method for confirming ETT placement. It outperforms auscultation and should be considered as an adjunct, or even a replacement, in perioperative and critical care airway management. Broader adoption of POCUS may improve patient safety, particularly in high-risk or resource-constrained settings.
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