The role of bedside ultrasound during tracheal intubation procedure

Tracheal intubation in complex settings (i.e. difficult airway, hemodynamic instability) means a challenging procedure [1]. It must be performed very quickly, being obviously essential to confirm the adequate positioning of the tube tip as soon as possible. Capnography is the most recommended tool in spite proper evaluation also includes clinical exam and X-ray, which implies some delay [2]. When capnography is not available and/ or misleading readings are present, bedside ultrasound can be extremely useful. The T.R.U.E. (Tracheal Rapid Ultrasound Exam) protocol consists on performing transverse bedside upper airway ultrasonography, by placing a linear transducer over the suprasternal notch [3]. At this level, tracheal and oesophagus are easily identified. In case of unnoticed oesophageal intubation, a gas artifact emerges in the oesophagus lumen. To definitively confirm the optimal tracheal tube position, regardless the absence of oesophageal gas artifact, left lung sliding must be checked in order to rule in/out a selective bronchial intubation. We show a case of failed tracheal intubation where clinical exam and capnography resulted inconclusive, and finally confirmed by bedside ultrasound.