Verification of ET Tube Placement

The American College of Emergency Physicians endorses the following principles regarding the confirmation of endotracheal tube placement in the emergency department or in the out-of-hospital setting.

• During intubation, direct visualization of the endotracheal tube passing through the vocal cords into the trachea constitutes firm evidence of correct tube placement, but should be verified with additional techniques.
• Verification of endotracheal tube placement should be completed in all intubated patients, and reconfirmation of endotracheal tube position should be done in all patients when their clinical status changes, or when there is any concern about proper tube placement.
• Standard physical examination methods, such as auscultation of lungs and epigastrium, visualization of chest movement, and fogging in the tube, are not sufficiently reliable to exclude esophageal intubation in all situations.
• Verification techniques include capnometry, esophageal detection devices, and revisualization with direct laryngoscopy.
• End-tidal CO2 detection, either qualitative, quantitative, or continuous, is the most accurate and easily available method to monitor correct endotracheal tube position in patients who have adequate tissue perfusion.
• Pulse oximetry and esophageal detector devices are not as reliable as end-tidal CO2 determinations in patients who have adequate tissue perfusion.
• For patients in cardiac arrest, and for those with markedly decreased perfusion, when end-tidal CO2 does not confirm tracheal intubation, other methods of confirmation, such as direct visualization, should be done.