Placement of Endotracheal Tube

Purpose

When patients are intubated, it is critical for successful ventilation that the tube tip is within the mid trachea. ET Tubes that are too low or too high can lead to serious complications such as under ventilation, cuff leak, or tracheal injury and therefore need to be repositioned and reimaged.

Tag(s)

 

Panel

Thoracic

Define-AI ID

20080024

Originator

Christopher P. Gange

Panel Chair

Carol C. Wu

Panel Reviewers

John Newell, Raym Geis, Stephen Hobbs, Warren Gefter, Scott J. Adams, Carol C. Wu

License

Creative Commons 4.0
Status Public Comment
RadElement Set RDES179
                               

Clinical Implementation


Value Proposition


Identifying a misplaced ET tube quickly would improve clinical management in the most critically ill patients by improving the odds of successful ventilation.  It could also improve post-operative management as hypoxia from a misplaced tube can slow recovery.  Unfortunately, at many hospitals there are a very large  number of portable chest X-rays performed causing a delay between when the tube is placed and when misplacement is discovered.


An algorithm which could take a chest radiograph  and quickly determine if a tube is misplaced could send an alert to the radiologist or flag the study on a worklist which should decrease the time until providers are notified and lead to more rapid correction.


Narrative(s)


A 30yo brought to the hospital after a drug overdose has to be intubated in the emergency department for airway protection.  The endotracheal tube was placed too low and only the right lung is being ventilated.  A few minutes after intubation, the ED providers are concerned about continued hypoxia.  A chest radiograph is taken, and images are automatically analysed by an AI engine. The AI engine reports a  potentially malpositioned tube and sends a notification flag to PACS prioritizing the chest radiograph for a radiologist's review, above several others that were taken near the same time. . The radiologist immediately interprets the radiograph, confirms that the ET tube is malpositioned, and communicates this critical finding to the referring clinical team, resulting in timely repositioning of the ET tube, and an improvement in clinical status of the patient."


Workflow Description



All chest radiographs obtained from the modality are sent to PACS and the AI engine. The image is analyzed by the engine. The system first determines if an endotracheal tube is present.  If present, the system will assess the tip location and the location of the carina.   The difference in those coordinates will be returned, and checked against a  preset criteria for appropriate position (usually 2-6 cm). If an abnormal position is found, an alert message is sent to PACS from the engine with the information about the current study, including the distance from the carina to the ET tube tip and a graphic overlay showing the suspected position of the tube tip and the carina.


Considerations for Dataset Development



Procedure

Chest XRAY

View(s)

PA or AP views

Age

18-100

Sex at birth

Male, Female

Comorbidities

pleural air or fluid (including air/fluid levels), lung disease (e.g., Pneumonia, emphysema, bronchiectasis), recent trauma, recent surgery, altered mental status


Other lines and tubes

Central venous catheters, pleural chest tubes, ECMO canulas, enteric tubes, pacer devices.

Technical Specifications


Inputs

 

DICOM Study

Procedure

Chest XRAY

Views

AP,PA, Lat

Data Type

DICOM

Modality

XRAY

Body Region

Chest

Anatomic Focus

Lung




Primary Outputs


ET Tube Detection

RadElement ID

RDE1247

Definition

Detect if an endotracheal tube is present

Data Type

Categorical

Value Set

  • Absent

  • Present

  • Unknown

Units

N/A



Location of ET Tube Tip

RadElement ID

RDE1248

Definition

Determine location of ET tube tip and define coordinates of location

Data Type

Coordinates

Value Set

N/A

Units

N/A



Location of the carina

RadElement ID

RDE1249

Definition

Determine the location of patient’s carina and define coordinates of location

Data Type

Coordinates

Value Set

N/A

Units

N/A



Position of ET Tube with respect to the carina

RadElement ID

RDE1250

Definition

Measure the distance between the coordinates for ET tube tip and carina

Data Type

Numeric

Value Set

N/A

Units

cm




ET Tube Position Appropriateness

RadElement ID

RDE1251

Definition

Determine position appropriateness based on the coordinates of the location of the ET tube tip, the carina, and a preset normal range

Data Type

Categorical

Value Set

  • ET tube is not in far enough

  • ET tube is correctly positioned

  • ET tube is in too far

Units

N/A