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Airway Ultrasound: Once Again, Challenging Our Current Standards.

Pediatric Critical Care Medicine www.pccmjournal.org 689 Ultrasound, in the hands of nontraditional imaging specialists (i.e., noncardiologists and nonradiologists), has become an pluripotent tool for image acquisition and real-time interpretation by pediatric critical care providers and anesthesiologists (1, 2). Practitioners have adapted a number of novel, “point-of-care” ultrasound applications specific to pediatric airway management, broadly ranging from difficult airway assessment to confirmation of endotracheal tube (ETT) position. For example, in an ultrasound-based scoring system developed to identify patients at risk for difficult airway, measurement of the hyomental distance and inability to visualize the hyoid bone have been associated with difficult intubation in adults (3, 4). Identification of the cricothyroid membrane is easily achieved by ultrasound and is superior to landmark-based identification when preparing for intubation in patients at high risk for conversion to surgical cricothyroidotomy (5). Ultrasound has demonstrated superiority for ETT size selection compared to traditional formulas (6). It has been shown repeatedly that “point-of-care” ultrasound both accurately discriminates endotracheal from esophageal intubation (7) and identifies the ETT within the trachea (which is particularly salient in patients with low pulmonary blood flow during cardiac arrest with ineffective chest compressions when endtidal carbon dioxide may be spuriously low) (8). In this issue of Pediatric Critical Care Medicine, Uya et al (9) reported a prospective study assessing the accuracy of ultrasound-based evaluation of ETT tip position in children undergoing cardiac catheterization. They found that 100% of saline-filled ETT cuffs were visualized by ultrasound and that the position of the ETT tip was below the level of providing feedback, therefore, the document may not be a true representation of the entire PCCM practicing community. In addition, although this is an excellent and rigorous document, it certainly required a major time commitment by both the task force and the multiple participants. This workload may not be applicable to other specialties or subspecialties. As PCCM practitioners, we have increasing demands on our time, including clinical workload, teaching commitments, and research productivity, among others. In this era, we struggle to acquire and maintain the knowledge and skills essential to stay current and proficient in the practice of PCCM. Demands on our time are certainly not lessening, and this practice analysis provides a timely, modern, and comprehensive resource that is valuable for all levels of learning within our specialty.