Archives of Academic Emergency Medicine. 2021; 9(1): e38 https://doi.org/10.22037/aaem.v9i1.1148 LE T T E R TO ED I TO R Tactile Method in Confirming Proper Endotracheal Intu- bation in Emergency Setting; a Letter to Editor Behrang Rezvani Kakhki1, Mohsen Miri1, Morteza Talebi Doluee1, Zeynab Sabeti Baygi2, Zahra Abbasi Shaye3, Elnaz Vafadar Moradi1∗ 1. Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran. 2. Department of Obstetrics and Gynaecology, Faculty of Medicine, Mashhad university of Medical Science, Mashhad, Iran. 3. Clinical Research Development Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Received: April 2021; Accepted: April 2021; Published online: 9 May 2021 Cite this article as: Rezvani Kakhki B, Miri M, Talebi Doluee M, Sabeti Baygi Z, Abbasi Shaye Z, Vafadar Moradi E. Tactile Method in Con- firming Proper Endotracheal Intubation in Emergency Setting; a Letter to Editor. Arch Acad Emerg Med. 2021; 9(1): e38. Dear Editor, Orotracheal intubation is one of the sure ways to manage air- ways in critical patients (1, 2). Failed intubation (Failure to properly place the endotracheal tube (ETT) in trachea) is a rather common event (3). There have been many techniques to confirm proper intubation, but none of them are applica- ble in all conditions. Methods such as capnography, tracheal sonography and chest-X-ray, were introduced for verification of proper tracheal intubation but they have their own limi- tations (4, 5). Given the significance of proper airway man- agement, the authors focused on a secondary method of ver- ifying proper intubation using tracheal tactile method and compared it to existing methods. This cross-sectional study was conducted on patients in need of intubation at Emergency Departments of Emam Reza, Ghaem, and Hasheminejad Hospitals of Mashhad, Iran. Patients with abnormal airway anatomies, cardiopul- monary arrest, severe cervical trauma, and tracheal or en- dobronchial traumas with increased risk of aspiration were excluded. Ethics Committee of Mashhad University of Medi- cal Sciences approved the protocol of this study (Ethics code: IR.MUMS.fm.REC.1395.644). Orotracheal intubation was performed for all participants and at the same time a well- trained expert (resident) touched the trachea (thumb and in- dex finger on both sides of the trachea under the Adam’s ap- ple) without applying any pressure. When the tube was in- serted, he/she would tell whether he/she thought the tube was properly placed. Other than tactile method, capnog- ∗Corresponding Author: Elnaz Vafadar Moradi; Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran. Email: Vafadarme@mums.ac.ir, Tel: +989151178625.ORCID: https://orcid.org/0000-0001-9579-7451 raphy, chest auscultation, and chest-X-ray (all 3 measures) were performed for confirmation of ETT placement (as gold standard) in all cases. Cases in which 2 out of 3 methods, one of which was always capnography, confirmed the proper lo- cation of ETT, were considered as proper intubation. Finally, 181 patients with mean age of 71.2 ± 16 years were studied (58.8% male). Based on the tactile method, in 161 (89%) cases, the tube had passed into the trachea. However, other methods confirmed proper intubation in 171 (94.5%) cases. Sensitivity, specificity, and positive and negative pre- dictive values of tactile method in confirmation of proper placement of endotracheal tube were 93% (95% CI: 88%- 95%), 80% (95% CI: 76%-83%)), 98.7% (95% CI: 96%-100%), and 40% (95% CI: 38%-44%), respectively. In addition, pos- itive and negative likelihood ratios of tactile method in this regard were 4.65 and 0.087, respectively. With the tactile method, it was observed that there were 159 cases of true positive and 12 cases of false positive, which could be due to shortage of time and poor technical skills due to little expe- rience in the tested method. It seems that, the method may perform much better with more time and practice. Our results support the results of Gamble et al. performed on 50 children between 2 and 10 years old, who were divided into 3 groups based on tactile confirmation of ETT placement through their suprasternal notch (6). Eventually, they con- cluded that the tactile method provided better clinical results than Pediatric advanced life support (PALS) formula in guid- ing intubation. McKay et al. studied 77 people and observed that tactile ETT tube placement confirmation via the suprasternal notch was easy or relatively easy in 60 cases, and hard or impossible in 17. They concluded that higher age, diabetes and smok- ing were associated with rigidity in tracheal rings, which pre- vents a good sense of touch on the intubation site (7). Their This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Rezvani Kakhki et al. 2 results match those of the present study with one difference; the effects of underlying factors on verification of tracheal intubation were not evaluated in the present study, but will hopefully be the subject of future studies. According to the authors’ findings, it could be concluded that the tactile technique is a quick, inexpensive, accurate and risk-free technique to verify proper ETT placement without any need for special equipment or skills. 1. Declarations 1.1. Acknowledgment The authors would like to express their sincerest apprecia- tions for cooperation and contributions of Ghaem, Emam Reza, and Heshemi Nezhad hospitals in Mashhad, operating under supervision of Research Department of Mashhad Uni- versity of Medical Sciences. 1.2. Authors’ contributions Study concept and design: BRK, MM Acquisition of the data: MM, MTD, ZAS Analysis and interpretation of the data: ZAS, EVM Drafting of the manuscript: EVM Critical revision of the manuscript for important intellectual content: All the authors Statistical expertise: ZSB Acquisition of funding: EVM, BRK 1.3. Conflicts of interest There was no conflict of interest in this study. 1.4. Funding support None. References 1. Ahmadi K PE, Ramezani M, Ebrahimi M. Sonography as a Secondary Technique for Confirming the Location of the Tracheal. Journal of Mashhad University of Medical Sci- ences. 2014:236-42. 2. Abbasi S FD, Zare M.A, Hajimohammadi M, Rezai M, Hafezimoghadam P. Direct ultrasound methods: a confir- matory technique for proper endotracheal intubation in the emergency department. European Journal of Emer- gency Medicine. 2015;22(1):10-6. 3. Park SC RH, Yeom SR, Jeong JW, Cho SJ. Confirmation of endotracheal intubation by combined ultrasonographic methods in the emergency department. . Emerg Med Aus- tralas. 2009;21:293-7. 4. Weaver B LM, Blaivas M. Confirmation of endotra- cheal tube placement after intubation using the ultra- sound sliding lung sign. Academic Emergency Medicine. 2006;13:239-44. 5. Sitzwohl CH LA, Schober A, Krafft P, Sessler D, et al. En- dobronchial intubation detected by insertion depth of en- dotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;5943:341. 6. Gamble J. J MWP, Wang A. F, Yip K. A, O’Brien J. M, Plewes C. E. Three-finger tracheal palpation to guide en- dotracheal tube depth in children. . Paediatr Anaesth. 2014;24(0):1050-55. 7. 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