Resuscitation Ultrasound

ALS-conformed 

Resuscitation 

Ultrasound 

A concept with images and video clips of exam styles 

by 

Raoul Breitkreutz, MD (Frankfurt a.M. / Bad Rappenau) 

Domagoj Damjanovic, MD (Freiburg i. Brsg.) 

Tobias C. Schröder, MD (Frankfurt a.M.) 

Markus Geuting, MD (Bad Rappenau) 

A free online publication of the 

The Scientific Network SonoABCD with SonoSchool 

and SonoABCD Publishing Company 

D-64405 Fischbachtal, Germany 

ISBN - 978-3-96228-078-9 

Available at yumpu.com/en/SonoABCD

ABCD

Sonoscopy of trachea in emergencies 

Tracheal and Esophageal tube placement 

- Simple pattern recognition - 

Normal: Single (airway) tract 

Double (airway) tract sign* 

Edited by Raoul Breitkreutz (2020) 

Scientific Network SonoABCD 

The fine art of Sonoscopy. 

No ventilation required. 

Observe: both lateral regions of airway tract 

*Zechner P, Breitkreutz R Resuscitation 2011 

Chou et al. Resuscitation 2011

Airway Ultrasound Exam 

Main Questions 

In emergency always use post-intubation check of trachea only. 


#Q1. Esophageal misplacement? Yes or No? 

Only if ruled out - goto 2. 

#Q2. Main stem intubation? Yes or No? 

If ruled in - slightly withdraw and re-check. 



Available at www.yumpu.com/en/SonoABCD

Distinct clinical emergency scenarios define 

two widely different tracheal ultrasound exam methods 

Exam style #1: Post-intubation check 

(e.g. CPR at point-of-care or on arrival at shock room) 

- immediate, urgent action - 


On-off evaluation 


The fine art of Sonoscopy.

Team H.K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019) 


#Q1 - Esophageal misplacement? Yes or No? 




In emergency always use post-intubation check of trachea only.




Finding 1a: No, normal! 




Edited by Raoul Breitkreutz (2020)

Sonoscopy of trachea post-intubation 

Check tracheal tube placement 

Exam style #1 - Simple pattern recognition 


Single (airway) tract 




No ventilation required.




Finding 1b: Yes! Immediate correction! 





Sonoscopy of trachea post-intubation 














Exam style #2: Visualization 

during entire intubation process 

(e.g. RSI, teaching) - planned action - 

Continuous evaluation 






Exam style #2: Visualization 

during entire intubation process 

(e.g. RSI, teaching) - planned action - 

Continuous evaluation 




Nota bene: 

1st trial —> esophagus. 

Upon instruction of clinician supervisor, 

observing by sonography, 

—> uninterrupted 2nd trial. 

With support of M. Nickel, MD and M. Geuting, MD, Bad Rappenau

Sonoscopy of trachea during intubation 




- unspectacular observation - 


prominent monitoring observation 

(2 attempts and withdrawals) 








Comparison of 

Clinician sonographer 

Probe movement 

at frontal neck 

Supervision 

Immediate correction? 

Action of sonographer? 

Exam styles 

#1 #2 

post-intubation 

active, 

exploration of region 

yes, onto and away 

dynamic 

no add role 

or not necessary 

no, 

check only 

during entire 

intubation process 

passive 

no, still /static 

waiting for action 

active option for role, 

e.g. in teaching 

yes, 

option to correction 

while indwelling ETT 

Image as is can change markedly 

Time (secs)

Team K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019) 


#Q2 - Main stem intubation? 

Extension of trachea check (exam style 1) and addition of the evaluation of lung motion 



In emergency, after tracheal check, start lung sliding evaluation 

at left hemithorax. In this scenario, there was no emergency. 


Team K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019) 



Finding 2a: No, normal! 




In emergency, after tracheal check, start lung sliding evaluation at left hemithorax.

Sonoscopy of lung post-intubation 

Check for lung pulse / lung sliding 

Simple pattern recognition 




Observe: 

Lung Sliding. No full ventilation cycle required.







Observe: Lung Sliding. No full ventilation cycle required.

Team Markus Geuting, M.D., M. Negele, Bad Rappenau, Germany (2019) 



Exam style #1 








Finding 2b: Yes, correction required! 











Observe: Lung pulse. 

Action: SlIghtly withdraw tube and re-check. No full ventilation cycle required. 








Observe: Lung pulse or lung sliding. 

Action: Slightly withdraw tube and re-check. No full ventilation cycle required. 



Limitations of the check for main stem intubation 

Interprete sonographic signs per hemithorax 

In presence of (known or unknown) pneumothorax 

Trachea ultrasound is applicable to check for normal or esophageal intubation. 

Lung ultrasound: Mainstem intubation cannot be diagnosed. The air in the pleural 

space, resulting in sonographic signs of pneumothorax (no lung sliding, no lung 

pulse, no B-lines) overlay signs of one-sided intubation. Pneumothorax still could 

be ruled in. 


In presence of (known or unknown) cardiac standstill 


Lung ultrasound: A firm statement regarding mainstem intubation is not possible 

for the finding will be similar to sonographic findings as in pneumothorax (such as 

no lung sliding and no lung pulse). Pneumothorax still could be ruled out (if lung 

sliding or B-lines are present). 

In presence of both pneumothorax and cardiac standstill 


Lung ultrasound: Neither mainstem intubation nor pneumothorax can be firmly 

diagnosed. 




Finding 3: no lung sliding, no lung pulse 




Consider pneumothorax, but only when heart beats!







Observe: Lung movements during ventilation. 

Think: If none, consider pneumothorax, but only if cardiac motion has been confirmed. 

Action: Decide side, consider or perform immediate needle puncture.

Additional information 

Esophageal misplacement? 

Comparing methods 

Ultrasound and Capnometry 



3 2 

Use B-Mode 

Regarding the question 

of esophageal misplacement, in 

post-intubation check of trachea, 

ultrasound is faster and 

does not require ventilation trials. 

Capnometry is slower and 

insecure for this purpose 

because of slow drop, requirement of ventilation trials and not providing zero line results 

Zechner PM, Breitkreutz R 

Resuscitation (2011)



Main questions 


#Q1. Esophageal 

misplacement? Yes or No? 

Esophageal misplacement? 

Re-Check after re-intubation 

Immediate action? 

Yes 

No, if 

normal 

Expected frequency 

ruling in 

ruling out 

#Q2. Main stem 

Main stem intubation? 

intubation? Yes or No? 

Re-Check after withdrawal 

Yes 

No, if 

normal 





Airway Ultrasound Exam 1,2 

Method 


Method: Sonoscopy 

Sonoscopy is the art of stethoscope-like use 

of ultrasound. 

Regarding Airway and Lung Ultrasound as part 

of „Resuscitation Ultrasound“ in the clinical 

context of Peri-Resuscitation: Check for trachea 

post-intubation, and, in case of tracheal 

placement, for lung sliding and -pulse. 




Types of airway ultrasound exams within a defined clinical context 

Types of airway ultrasound exams 

within a defined clinical context 

Action / ultrasound 

exam type 

Aim, emphasis on 

Approx. time for 

exam (seconds) 

Time pressure? 

/ remark 

Pre-check, e.g. for 

prep of dLT, difficult 

laryngoscopy, 

identify cricoid 

membrane 

planned evaluation 

of upper airway 

related 

sonoanatomy 

> 60 

no time pressure 

applicable, because of 

measurements 

Trachea exam only 

after any emergency 

intubation, double 

tract or single tract 

before ventilation 

< 10, when 

evaluating postintubation 

only 

yes, integration into a 

(fast driving) process, 

similar to one by one item 

in a RSI 

Airway Ultrasound 

Exam 

Airway Ultrasound as 

part of Resuscitation 


routine check for 

trachea plus lung 

sliding or lung pulse 

or diaphragm or 

parts of it 

check of treatable 

conditions 

< 120 no, variety of indications* 

A;

Airway Ultrasound Exam 1,2 

References 

Slovis TL, Poland RL. Radiology. 1986; 160:262–3. 

Endotracheal tubes in neonates: (Its) sonographic positioning. 

Raphael DT, Conard FU. Ultrasound confirmation of endotracheal tube placement. 

J Clin Ultrasound. 1987; 15:459–62. 

Ma G et al. J Emerg Med 1999 (SAEM meeting Abstract 515), Acad Emerg Med. 1999; 6:515. full paper 

published in 2007 (Trachea, while and post-intubation, principle, cadavers) 

Drescher MJ et al.. Acad Emerg Med 2000;7:722–5. 

(First detailed description of sonograms in esophageal intubation, while and post-intubation, principle, 

cadavers) 

Weaver B et al. Acad Emerg Med. 2006;13(3):239-44 

(Lung sliding to confirm trachea placement, post-intubation, principle, cadavers) 

Ma G et al. J Emerg Med 2007;32:405 (Trachea, while and post-intubation, principle, cadavers) 

Werner SL et al. Ann Em Med 2007;49:75–80 (Trachea, while intubation, principle) 

Chou HC et al Resuscitation 2011;82:1279–84 (Trachea, while intubation, double tract sign) 

1Zechner P, Breitkreutz R Resuscitation 82 (2011) 1259–61 (First description of the 

„Airway ultrasound protocol“, combining ALS-conformed trachea and lung evaluation) 

2Breitkreutz R et al. Resuscitation 83 (2012) 273–274 (add of Lung sliding, Lung pulse) 


Adi O et al. Crit Ultrasound J 2013; 5:7 (Trachea, Post-intubation) 

Abbasi et al. Eur J Emerg Med 2015;22(1):10–6 (Trachea, Post-intubation) 

Soar J et al. Resuscitation 95 (2015) 100-142 (ERC guideline 2015) 

Chou EH et al. / Resuscitation 90 (2015) 97–103 (Metaanalysis) 



Additional exam styles 

Sonoscopy of lung post-intervention 

Ruling out pneumothorax 






Think: If lung sliding or lung pulse are present, you can rule out pneumothorax. 

Action: Perform planned repeated exam two-staged in clinical time course.


Sonoscopy of lung: Screening for pleural effusion 





Observe: Lung sliding, diaphragm 

Think: separation of diaphragm and lung? 

Action: evaluate clinical symptoms for puncture decision and if urgent


Sonoscopy tests of double lumen intubation 



by Tobias C. Schröder, Frankfurt a.M. 




Think: Lung sliding or lung pulse if not clamped or clamped. 

Action: Visualisation, clamping, visualisation and conclusion


Sonoscopy test of congestion - B-lines 





Observe: B-lines, multiple B-lines, effusion. 

Think: multiple B-lines? bilateral? white lung? 

Action: reporting, oxygen, induction of therapy

Review article 

nt, especially in its specificity value. Different settings, operperience, 

Ultrasonography and timing of the for ultrasound confirmation can cause of a endotracheal small but was tube used placement: 

in ten studies. 9,11,12,14–20 The sensitivity and spe 

mon ultrasound technique to detect esophageal intubatio 

nificant A influence on the diagnostic accuracy. Ultrasonogran 

be a useful tool for confirmation of tracheal intubation. real-time sonographic imaging during intubation has higher 

are both high in cadaveric models, ORs, and EDs. In ge 

systematic review and meta-analysis 

er, Eric the use H. Chou of ultrasonography a,1 , Eitan Dickmanor a , any Po-Yang method Tsouas b , Mark the sole Tessarotivity a , Yang-Ming for detection Tsai c , of esophageal Additional intubation information 

than post-intu 

Matthew Huei-Ming Ma d , Chien-Chang Lee c,d,∗ , John Marshall a 

a Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA 

b College of Medicine, National Yang-Ming University, Taipei, Taiwan 

c Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan 

d Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan 

Resuscitation 90 (2015) 97–103 

a r t i c l e i n f o 

Article history: 

Received 19 November 2014 

Received in revised form 11 February 2015 

Accepted 12 February 2015 

Keywords: 

Intubation 

Airway management 

Ultrasonography 


Meta-analysis 

Critical care 

a b s t r a c t 

Objective: This study aimed to undertake a systematic review and meta-analysis to summarize evidence 

on the diagnostic value of ultrasonography for the assessment of endotracheal tube placement in adult 

patients. 

Methods: The major databases, PubMed, EMBASE, and the Cochrane Library, were searched for studies 

published from inception to June 2014. We selected studies that used ultrasonography to confirm endotracheal 

tube placement. The search was limited to human studies, and had no publication date or country 

restrictions. Exclusion criteria included case reports, comments, reviews, guidelines and animal studies. 

Two reviewers extracted and verified the data independently. We summarized test performance characteristics 

with the use of forest plots, hierarchical summary receiver operating characteristic (HSROC) 

curves, and bivariate random effect models. Meta-regression analysis was performed to explore the 

source of heterogeneity. The methodological quality of individual studies was evaluated using the Quality 

Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 

Results: A total of 12 eligible studies involving adult patients and cadaveric models were identified 

from 1488 references. For detection of esophageal intubation, the pooled sensitivity was 0.93 (95%CI: 

0.86–0.96) and the specificity was 0.97 (95%CI: 0.95–0.98). The area under the summary ROC curve was 

0.97 (95%CI: 0.95–0.98). The positive and negative likelihood ratios were 26.98 (95%CI: 19.32–37.66) and 

0.08 (95%CI: 0.04–0.15), respectively. 

Conclusions: Current evidence supports that ultrasonography has high diagnostic value for identifying 

esophageal intubation. With optimal sensitivity and specificity, ultrasonography can be a valuable adjunct 

in this aspect of airway assessment, especially in situations where capnography may be unreliable. 

© 2015 Elsevier Ireland Ltd. All rights reserved. 

1. Introduction 

Tracheal intubation serves as definite airway control when 

resuscitating critically ill patients. Confirmation of proper tube 

placement should be completed in all patients at the time of initial 

intubation. Unrecognized misplacement of the endotracheal tube 

may lead to avoidable morbidity including neurological damage, 

and death, with a reported incidence of 6–16%. 1,2 Thus, immediate 

post-intubation airway assessment is an essential clinical skill 

for every physician in emergency medicine (EM), anesthesia and 

critical care medicine. There are multiple options for confirming 

tracheal intubation and all methods have unique limitations. 3–5 

According to the 2010 American Heart Association (AHA) guideline,

Breitkreutz R et al. (2012) 

Additional 

information 






Consider obtaining findings. Don´t try diagnoses. 


Decide C-AB or A-B-C or else upon clinical context. 

Don´t get distracted by insecure interpretation of a finding. 

Team leaders should decide CPR process independently. 

B-Mode provides overview and is fast. Avoid M-Mode for lung 

evaluation in emergencies because of lesser overview and time consuming 

interaction with the ultrasound machine. 

Consider this method as secondary option whenever available. With 

ultrasound or capnometry you cannot intubate. However, with 

bronchoscopy you could. 

Train tracheal quick check, lung sliding or pulse and subcostal 

window. On yourself or in any health environment. These are very simple 

exams 



ABCD

30% VF only 

>60% PEA / asystole

The problem is…. 

High-quality CPR! 

Identify treatable 

conditions! 

How to integrate ALS-conformed ultrasound in (existing) interruptions?

The solution is 

1) With training 

ALS-conformed ultrasound is feasible. 

2) It has a potential to identify 

- tamponade 

- acute right heart pressure overload 

- hypovolemia. 

3) Minimize interruptions!

2015

2015

2015 

„Consider“ ≙ VAS 5!

2016 

1. Cardiac activity on ultrasound was most 

associated with survival following cardiac 

arrest. 

2. Ultrasound during cardiac arrest identifies 

interventions outside of the standard ACLS 

algorithm.

2018

Is Resuscitation Ultrasound = „Emergency TTE“? 

Main emphasis on 

Findings 

Probe positions 

Further regions 

Method of evaluation 

Resuscitation Ultrasound 

resume chest compressions, driving force is 

ALS, identify treatable conditions, image at 

a glimpse only 

Pathologies (3) and „kinetic activity“ 

2: cardiac, cava (sweep in subcostal area) 

A: airway - trachea only, post-intubation for 

observing single or double tract 

B: lung (sliding, pulse) main stem intubat. 

Screening, „Scanning“, simple gross 

pathologies, binary answer 

Emergency TTE 

function, acquisition of 

various views 

Pathologies (>10) and 

functional analysis 

5+: parasternal LAX, 

SAX, apical, subcostal, 

IVC LAX… 

- 

Diagnostic accuracy, 

quantitative information 

Duration 400 PoCUS 

longer time spans 

full specialized TTE 

training 

Concept with 

DEGUM / ÖGUM / SGUM



low-cost, available at 

www.SonoABCD-Verlag.org

Sweep subcostal-LAX - IVC

During CPR 

subcostal window 


Raoul Breitkreutz, Scientific Network Scientific Network SonoABCD 


During CPR: EMD 


interruption 

pause of chest compressions 

evaluation 




asystole, after 

cessation no flow 





True - EMD 

parasternal, LAX 

Courtesy of H. Steiger, Darmstadt 



Pseudo - EMD 

parasternal, LAX 

Courtesy of H. Steiger, Darmstadt 



Tamponade 





Tamponade 


parasternal, SAX 

same patient 


Field examples, pocket-sized devices 




Signs of acute right heart pressure overload 

subcostal 4-chamber view 




Signs of acute right heart 

pressure overload 

parasternal window, SAX 




two patients 

Field examples, pocket-sized devices 


Signs of acute right heart 

pressure overload 

parasternal window, SAX 

immediately after ROSC 




Signs of hypovolemia 

IVC, SAX, transhepatic view 




Field example, pocket-sized device 

after ROSC 


Signs of congestion 

IVC, SAX, transhepatic view 


IVC , eye-balling, B-Mode 


„eye-balling“ evaluation 

✓1. diameter (end-expiratory) < 1,5 cm? 

✓2. pulsation visible? 

ev. 3. respiratory variability? 0-50% 

- (in CPR no sniff test to assess “collapsibility”) 



IVC, B-Mode, LAX, “eye-balling” 




VCI, LAX - Pitfall false Diameter (fD)! 

- n o horizontal diameter 

- vertical diameter: median or not? 


fD 



after Scheiermann P et al. Ultraschall in der A&I, Kapitel 7.2., DÄV (2007)

(very) low EF - eyeballing 

sweep of IVC and 

subcostal 4-chamber view 

1st exam after ROSC 




Therapy: Puncture/Aspiration, Lysis, Volume, Catecholamines 

ER / ICU / shockroom - system has to be prepared - What about yours? 

Decide! 

If diagnostics - prepare also for therapy! 


http://leitlinien.dgk.org/ 

e.g.. 1:10 

(100 µg/ml) 



Immediate 

(specialist / cardiologist was informed but immediate action was required) 

Emergency: First aspiration / withdrawal of fluid to unload pressure! 




Urgent 

(specialist / cardiologist was informed but not available) 






Emergencies: main goal if tamponade 

unload pressure = puncture + aspiration/withdrawal 

Catheter insertion takes time. Can be done later! 

puncture / withdrawal 


no primary catheter insertion

ALS-conformed 



A concept with images and video clips of exam styles 

by 

Raoul Breitkreutz, MD (Frankfurt a.M. / Bad Rappenau) 

Domagoj Damjanovic, MD (Freiburg i. Brsg.) 

Tobias C. Schröder, MD (Frankfurt a.M.) 

Markus Geuting, MD (Bad Rappenau) 

A free online publication of the 

The Scientific Network SonoABCD with SonoSchool 

and SonoABCD Publishing Company 

D-64405 Fischbachtal, Germany 

ISBN - 978-3-96228-078-9 


Acknowledgement 

This work is dedicated to WINFOCUS, a non-profit organization. 

Ideas are results of mutual scientific exchange with world leading experts 

in the field of focused ultrasound now more known as „point-of-care ultrasound“. 

We gathered at several annual congresses and consensus conferences 

and listened and learned and talked with empathy and enthusiasm. 

WINFOCUS´ vision is to spread the ideas 

of the new methods of sonoscopy to the one world.

Resuscitation Ultrasound

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