Skip to main content
  • Original article
  • Open access
  • Published:

Role of ultrasound in airway assessment in the respiratory ICUs

Abstract

Background

Airway evaluation and its management remain an emerging clinical science. Ultrasound (US) provides point-of-care dynamic views of the airway in perioperative, emergency, and critical care settings. Identification of a difficult airway before intubation allows for optimal preparation, equipment selection, and participation of experienced personnel.

Objective

The aim of this study was to evaluate the role of US in the assessment of airways and to determine whether US has the potential to serve as an effective, noninvasive method for the diagnosis of tracheomalacia.

Patients and methods

A prospective cross-sectional study was carried out on patients admitted at the respiratory ICU. US examination of the airways and diaphragm was performed together with either fiberoptic bronchoscopy (FOB) or dynamic expiratory computed tomography chest. Dynamic expiratory computed tomography chest and FOB were done within 24h of US examination.

Results

A total of 53 patients were included. US could successfully confirm endotracheal tube (ETT) placement in all patients. ETT was endotracheal in 30 (94%) patients, whereas it was esophageal in two (6%) patients. Hyomental distance at a cut-off of up to 4.51cm was a good predictor of difficult intubation with 100% sensitivity and 87.5% specificity. Subglottic airway transverse diameter was used as a predictor of ETT size. Patients with tracheomalacia by FOB had a significantly longer duration of mechanical ventilation. Lateral pharyngeal wall thickness was used as a predictor of obstructive sleep apnea, a new cut-off point was used at more than 4.1 cm in the intubated group of patients with 87.5% sensitivity and 95.8% specificity, whereas a cut-off point more than 4.2 cm in the nonintubated patients had 100% sensitivity and 100% specificity. In the intubated group, out of the seven cases diagnosed with tracheomalacia by FOB, five patients were missed by US with 40% sensitivity, whereas in the nonintubated group, the results were significantly better, where only one case was missed by US with 80% sensitivity.

Conclusion

US has many advantages for imaging the airway; it is safe, quick, repeatable, portable, widely available, and provides real-time dynamic images relevant for several aspects of management of the airway. Thus, it seems reasonable to consider the routine use of airway US in the ICU.

References

  1. Garg R, Gupta A. Ultrasound: a promising tool for contemporary airway management. World J Clin Cases 2015; 3:926–929.

    PubMed  PubMed Central  Google Scholar 

  2. Beale TJ, Rubin JS. In: Orloff LA, editor. Laryngeal ultrasonography. San Diego: Plural Publishing; 2008. pp. 183–202.

    Google Scholar 

  3. Hall EA, Showaihi I, Shofer FS, Panebinco NL, Dean AJ. Ultrasound evaluation of the airway in the ED: a feasibility study. Crit Ultrasound J 2018; 10:3.

    PubMed  PubMed Central  Google Scholar 

  4. Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth view. Chest 2005; 127:984–1005.

    PubMed  Google Scholar 

  5. Lee KS, Sun MRM, Ernst A, Feller-kopman D, Majid A, Boiselle PM. Comparison of dynamic expiratory CT with bronchoscopy for diagnosing airway malacia: a pilot evaluation. Chest 2007; 131:758–764.

    PubMed  Google Scholar 

  6. Wahidi MM, Jain P, Jantz M, Lee P, Mackensen GB, Barbour SY, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia and sedation during flexible bronchoscopy in adult patients. Chest 2011; 140:1342–1350.

    CAS  PubMed  Google Scholar 

  7. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of sonography for airway assessment: an observational study. J Ultrasound Med 2010; 29:79–85.

    PubMed  Google Scholar 

  8. Osman A, Sum KM. Role of upper airway ultrasound in airway management. J Intensive Care 2016; 52:1–7.

    Google Scholar 

  9. Wojtczak JA. Submandibular sonography: assessment of hyomental distances and ratio, tongue size, and floor of the mouth musculature using portable sonography. J Ultrasound Med 2012; 31:523–528.

    PubMed  Google Scholar 

  10. Ezri T, Gewürtz G, Sessler DI, Medalion B, Szmuk P, Hagberg C, et al. Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia 2003; 58:1111–1114.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Tejesh CA, Manjunath AC, Shivakumar S, Vinayak P, Yatish B, Geetha CR. Sonographic detection of tracheal or esophageal intubation: a cadaver study. Saudi J Anaesth 2016; 10:314–316.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. Sustic A. Role of ultrasound in the airway management of critically ill patients. Crit Care Med 2007; 3:173–177.

    Google Scholar 

  13. Altun D, Sungur MO, Ali A, Bingül ES, Seyhan TO, Çamcı E. Ultrasonographic measurement of subglottic diameter for paediatric cuffed endotracheal tube size selection: feasibility report. Turk J Anaesthesiol Reanim 2016; 44:301–305.

    PubMed  PubMed Central  Google Scholar 

  14. Bae JY, Byon HJ, Han SS, Kim HS, Kim JT. Usefulness of ultrasound for selecting a correctly sized uncuffed tracheal tube for paediatric patients. Anaesthesia 2011; 66:994–998.

    PubMed  Google Scholar 

  15. Kundra P, Mishra SK, Ramesh A. Ultrasound of the airway. Indian J Anaesth 2011; 55:456–462.

    PubMed  PubMed Central  Google Scholar 

  16. Giassert HA, Burns J. The compromised airway: tumors, strictures, and tracheomalacia. Surg Clin North Am 2010; 90:1065–1089.

    Google Scholar 

  17. Kandaswamy C, Bird G, Gill N, Math E, Vempilly JJ. Severe tracheomalacia in the ICU: identification of diagnostic criteria and risk factor analysis from a case control study. Respir Care 2013; 58:340–347.

    PubMed  Google Scholar 

  18. Ernst A, Majid A, Feller-Kopman D, Guerrero J, Boiselle P, Loring SH, et al. Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study. Chest 2007; 132:609–616.

    PubMed  Google Scholar 

  19. Loring SH, O’Donnell CR, Feller-Kopman DJ, Ernst A. Central airway mechanics and flow limitation in acquired tracheobronchomalacia. Chest 2007; 131:1118–1124.

    PubMed  Google Scholar 

  20. Adnan M, Kumar G, Jully MS, Robert LB, Erik F, Sebastian FB, et al. Evaluation of tracheobronchomalacia by dynamic flexible bronchoscopy. Ann Am Thorac Soc 2014; 11:951–955.

    Google Scholar 

  21. Kerolous G, Ikladios O. Tracheomalacia and recurrent exacerbations of chronic obstructive pulmonary disease: a case report and review of the literature. J Community Hosp Intern Med Perspect 2016; 48:61–66.

    Google Scholar 

  22. Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, et al. Practice guidelines for management of difficult airway: a report by American Society of Anaesthesiologists Task Force on management of the difficult airway. Anesthesiology 1993; 78:597–602.

    Google Scholar 

  23. Wu J, Dong J, Ding Y, Zheng J. Role of anterior neck soft tissue quantifications by ultrasound in predicting difficult laryngoscopy. Med Sci Monit 2014; 18:2343–2350.

    Google Scholar 

  24. Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med 2011; 18:754–758.

    PubMed  Google Scholar 

  25. Komatsu R, Sengupta P, Wadhwa A, Akca O, Sessler DI, Ezri T. Ultrasound quantification of anterior soft tissue thickness fails to predict difficult laryngoscopy in obese patients. Anaesth Intensive Care 2007; 35:32–37.

    CAS  PubMed  Google Scholar 

  26. Kalezic N, Lakicevic M, Milicic B, Stojanovic M, Sabljak V, Markovic D. Hyomental distance in the different head positions and hyomental distance ratio in predicting difficult intubation. Bosn J Basic Med Sci 2016; 16:232–236.

    CAS  PubMed  PubMed Central  Google Scholar 

  27. Abraham S, Himarani J, Mary Nancy S, Shanmugasundaram S, Krishnakumar Raja VB. Ultrasound as an assessment method in predicting difficult intubation: a prospective clinical study. J Maxillofac Oral Surg 2018; 17:563–569.

    PubMed  PubMed Central  Google Scholar 

  28. Chun R, Kirkpatrick AW, Sirois M, Sargasyn AE, Melton S, Hamilton DR, et al. Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disaster Med 2004; 19:366–369.

    PubMed  Google Scholar 

  29. Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 8. Circulation 2010; 122:729–767.

    Google Scholar 

  30. Adi O, Chaun TW, Rishya M. A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation. Crit Ultrasound J 2013; 5:7.

    PubMed  PubMed Central  Google Scholar 

  31. Ma G, Davis DP, Schmitt J. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med 2007; 32:405–407.

    PubMed  Google Scholar 

  32. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the confirmation of endotracheal tube intubation: a systematic review and meta-analysis. Ann Emerg Med 2018; 72:627–636.

    PubMed  Google Scholar 

  33. Chou HC, Chong KM, Sim SS, Ma MH, Liu SH, Chen NC, et al. Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation. Resuscitation 2013; 84:1708–1712.

    PubMed  Google Scholar 

  34. Chou EH, Dickman E, Tsou P, Tessaro M. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation 2015; 90:97–103.

    PubMed  Google Scholar 

  35. Shibasaki M, Nakajima Y, Ishii S, Shimizu F, Shime N, Sessler DI. Prediction of pediatric endotracheal tube size by ultrasonography. Anesthesiology 2010; 113:819–824.

    PubMed  Google Scholar 

  36. Lakhal K, Deplace X, Cottier JP, Tranquart F, Sauvagnac X, Mercier C, et al. The feasibility of ultrasound to assess subglottic diameter. Anesth Analg 2007; 104:611–614.

    PubMed  Google Scholar 

  37. Husein M, Manoukian JJ, Patenaude Y, Platt R. Ultrasound and a new videobronchoscopy to assess the subglottic diameter in the paediatric population: a first look. J Otolaryngol 2002; 31:220–226.

    PubMed  Google Scholar 

  38. Isaiah A, Mezrich R, Wolf J. Ultrasonographic detection of airway obstruction in a model of obstructive sleep apnea. Ultrasound Int Open 2017; 3:34–42.

    Google Scholar 

  39. Liu KH, Chu WC, To KW, Ko FW, Tong MW, Chan JW, et al. Sonographic measurement of lateral pharyngeal wall thickness in patients with obstructive sleep apnea. Sleep 2007; 30:1503–1508.

    PubMed  PubMed Central  Google Scholar 

  40. Kocis KC, Radell PJ, Stenberger WI. Ultrasound evaluation of piglet diaphragm function before and after fatigue. J Appl Physiol 1997; 83:1654–1659.

    CAS  PubMed  Google Scholar 

  41. Jiang JR, Tsai TH, Jerng JS, Yu CJ, Wu HD, Yang PC. Ultrasonographic evaluation of liver/spleen movements and extubation outcome. Chest 2004; 126:179–185.

    PubMed  Google Scholar 

  42. Osman AM, Hashim RM. Diaphragmatic and lung ultrasound application as new predictive indices for the weaning process in ICU patients. Egypt J Radiol Nucl Med 2017; 48:61–66.

    Google Scholar 

  43. Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med 2011; 39:2627–2630.

    PubMed  Google Scholar 

  44. Saeed AM, El Maraghy AA, Raafat RH, Abd El SAmad AM. Assessment of diaphragmatic mobility by chest ultrasound in patients with chronic obstructive pulmonary disease on different modes of mechanical ventilation. Egypt J Bronchol 2019; 13:184–190.

    Google Scholar 

  45. Jokinen K, Palva T, Sutinen S, Nuutinen J. Acquired tracheobronchomalacia. Ann Clin Res 1977; 9:52–57.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marwa H. El-Assal MSc MSc.

Additional information

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ahmed, M.M., Galal, I.H.E., Sakr, H.M. et al. Role of ultrasound in airway assessment in the respiratory ICUs. Egypt J Bronchol 13, 672–683 (2019). https://doi.org/10.4103/ejb.ejb_59_19

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/ejb.ejb_59_19

Keywords