Stethoscopes, Intubation and COVID

[docB]

How do you guys deal with using a stethoscope during a COVID intubation? I’m having a lot of trouble not contaminating myself after I tube getting the scope into my ears. I’ve tried double gloving and that seem like the best way but I feel like I contaminate my wrists when I’m taking off the top gloves. I tried putting it in my ears before I start but the scope head invariably bangs on the gurney when I bend over to tube which is pretty uncomfortable.

Has anyone just given up on auscultation post intubation? With CO2 it’s probably not necessary. In my shops we don’t have waveform, just colorimetric.

We’re also out of disposable stethoscopes so we have to use our own and decon them after.

One thing I suggest is placing the OG for the nurses. We’ve all seen how tough that can be sometimes when they’re trying to do it blind and how much aerosol it can create. I use the laryngoscope and it’s usually easier. One thing I’m sure I can do is tube the esophagus.

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[NITRAS]

I saw some bluetooth stethoscopes that looked cool. Not sure how durable they are. They all seemed kinda expensive side. $250-$500 for basic steth. Also don't know the quality. I'm not snobby with steths, but I'm cheap.

 

[southerndoc]

COVID=no stethoscope

 

[Dr Mantis Toboggan]

I don’t perform any auscultation on my covid patients if I can avoid it. I pay more attention now to the black lines on the end of the tube. Only tricky part is detecting wheezing on asthma/COPD patients. If I absolutely have to listen it’s purple wipe city on that bad boy if there is no disposable available.

How do you guys deal with using a stethoscope during a COVID intubation? I’m having a lot of trouble not contaminating myself after I tube getting the scope into my ears. I’ve tried double gloving and that seem like the best way but I feel like I contaminate my wrists when I’m taking off the top gloves. I tried putting it in my ears before I start but the scope head invariably bangs on the gurney when I bend over to tube which is pretty uncomfortable.

Has anyone just given up on auscultation post intubation? With CO2 it’s probably not necessary. In my shops we don’t have waveform, just colorimetric.

We’re also out of disposable stethoscopes so we have to use our own and decon them after.

One thing I suggest is placing the OG for the nurses. We’ve all seen how tough that can be sometimes when they’re trying to do it blind and how much aerosol it can create. I use the laryngoscope and it’s usually easier. One thing I’m sure I can do is tube the esophagus.

 

[ShockIndex]

COVID=no stethoscope

You don’t know how much **** I got a week ago from saying exactly that. Nothing that I hear with my ears is going to trump what I see with my eyes on the capnograph.

 

[TheSingularity]

I haven't auscultated a single patient in 6 weeks.

 

[RPedigo]

Preoxygenate with NRB (or closed circuit) and 5L NC, RSI, no bagging, place ETT, hook up directly to ventilator. If desaturates and need to bag, place LMA to reoxygenate. Place ETT and if good sat and capno, no auscultation. Perform other procedures as necessary (central line, NG/OG), obtain one CXR subsequently. That's what we have been doing recently and it works out well.

 

[BoardingDoc]

The lungs are meant to be seen and not heard. Get a CXR. I haven't used a stethoscope in weeks. For post-intubation, I have waveform cap and then get a CXR.

 

[Brigade4Radiant]

Lol stethoscope? I just walk into the room with full PPE I don’t get closer than six feet. I do not touch them and during intubation the RT can ascultate after we place the tube through the cords

 

[southerndoc]

You don’t know how much **** I got a week ago from saying exactly that. Nothing that I hear with my ears is going to trump what I see with my eyes on the capnograph.

Luckily everyone is on board at my facility.

 

[thegenius]

How do you guys deal with using a stethoscope during a COVID intubation? I’m having a lot of trouble not contaminating myself after I tube getting the scope into my ears. I’ve tried double gloving and that seem like the best way but I feel like I contaminate my wrists when I’m taking off the top gloves. I tried putting it in my ears before I start but the scope head invariably bangs on the gurney when I bend over to tube which is pretty uncomfortable.

Has anyone just given up on auscultation post intubation? With CO2 it’s probably not necessary. In my shops we don’t have waveform, just colorimetric.

We’re also out of disposable stethoscopes so we have to use our own and decon them after.

One thing I suggest is placing the OG for the nurses. We’ve all seen how tough that can be sometimes when they’re trying to do it blind and how much aerosol it can create. I use the laryngoscope and it’s usually easier. One thing I’m sure I can do is tube the esophagus.

It might be easier to just decontaminate the stethoscope after leaving the room in a similar way you would decontaminate yourself.
wash it down with soap / water or Purell.

 

[Arch Guillotti]

Has anyone just given up on auscultation post intubation?

lol, yep.

 

[WilcoWorld]

When bag compliance, chest rise, capnography, and oximetry confirm tube placement - there's no need for a stethaphone.

 

[thegenius]

When bag compliance, chest rise, capnography, and oximetry confirm tube placement - there's no need for a stethaphone.

and CXR

 

[Angry Birds]

What's a stethoscope

 

[KGflyboy]

What's a stethoscope

It's my reflex hammer.

 

[Angry Birds]

It's my reflex hammer.

What's a reflex hammer

 

[deleted859535]

What's a reflex hammer

It's a stethoscope.

 

[docB]

Yeah I don't put a lot of stock in auscultation either usually. But these COVID patients can be tough. They seem to have a tendency to crump right after intubation because their diffusion capacity is shot. I had a guy 3 days ago who I tubed, was confident of the placement, who then got more hypoxic, bradyed and lost his pulse. I got him back with 1 round of CPR, epi, atropine. I visually verified the tube which is one of my favored things to do. I asculateted him and would feel compelled to do so again. I needed to know that I didn't have a mainstem or a PTX that was making it worse. I also use the stethoscope to verify the OG which I like to put down because I think I can do it more safely than the nurses. It's definitely old school but I don't think I can toss it completely just yet.

 

[Tiger26]

It's time we end the patient satisfaction theater that is auscultation

 

[turkeyjerky]

Personally, I'm a holdout on auscultation--I still find it clinically useful. How else are you going to detect bronchospasm?

But I've never found it useful for tube placement. I think it hurts more than it helps.

 

[thegenius]

Personally, I'm a holdout on auscultation--I still find it clinically useful. How else are you going to detect bronchospasm?

But I've never found it useful for tube placement. I think it hurts more than it helps.

You just check the CXR before making adjustments?

Personally I don't think auscultation is a high risk, or even medium risk, physical exam maneuver performed on most people with confirmed COVID. It may not be high yield, but it's highly unlikely you are going to get it

The patient is masked, perhaps even with an N95.
You, the doc, are gowned, gloved, N95, bootie on feet, bonnet on head, etc.

 

[Groove]

How do you guys deal with using a stethoscope during a COVID intubation? I’m having a lot of trouble not contaminating myself after I tube getting the scope into my ears. I’ve tried double gloving and that seem like the best way but I feel like I contaminate my wrists when I’m taking off the top gloves. I tried putting it in my ears before I start but the scope head invariably bangs on the gurney when I bend over to tube which is pretty uncomfortable.

Has anyone just given up on auscultation post intubation? With CO2 it’s probably not necessary. In my shops we don’t have waveform, just colorimetric.

We’re also out of disposable stethoscopes so we have to use our own and decon them after.

One thing I suggest is placing the OG for the nurses. We’ve all seen how tough that can be sometimes when they’re trying to do it blind and how much aerosol it can create. I use the laryngoscope and it’s usually easier. One thing I’m sure I can do is tube the esophagus.

I still auscultate but I wipe down my stethoscope with some germicidal/viricidal wipes afterwards that are in all our rooms. Intubation hasn't changed at all for me during COVID except that I wear PPE and I've switched from DL to using McGrath to keep my face away a little better. That's pretty much it.

 

[bravotwozero]

Because I wear a PAPR while intubating, and usually in a negative pressure room, the noise level makes any kind of auscultation attempt damn near useless. I don't even see the point in bothering...

 

[Angry Birds]

Personally, I'm a holdout on auscultation--I still find it clinically useful. How else are you going to detect bronchospasm?

But I've never found it useful for tube placement. I think it hurts more than it helps.

Nah I'm kidding. I loved auscultation before this covid thing ... precisely to listen for wheezes

Not for tube placement though

 

[turkeyjerky]

You just check the CXR before making adjustments?

Personally I don't think auscultation is a high risk, or even medium risk, physical exam maneuver performed on most people with confirmed COVID. It may not be high yield, but it's highly unlikely you are going to get it

The patient is masked, perhaps even with an N95.
You, the doc, are gowned, gloved, N95, bootie on feet, bonnet on head, etc.

I just place it based on patient sex and height. I still listen for show (I think nurses/RTs expect it) but never make adjustments based on what I hear.

 

[Groove]

You guys do realize that probably 95% of us are producing COVID-19 antibodies by now.

 

[bravotwozero]

I'll believe that when I have the antibody test results in front of me. Get me the test!

 

[Atlas Shrugged]

You can use ultrasound to confirm placement. Pocket ultrasound easier to sheathe and decontaminate.

American College of Emergency Physicians

There have been several studies investigating the sensitivity and specificity of ultrasound in confirmation of ETT placement, both in live and cadaveric models. In a systematic review and meta-analysis by Chou et al, a pooled sensitivity of 93% and specificity of 97% was determined for detection...

www.acep.org

Sent from my iPhone using SDN

 

[Angry Birds]

Personally, I'm a holdout on auscultation--I still find it clinically useful. How else are you going to detect bronchospasm?

But I've never found it useful for tube placement. I think it hurts more than it helps.

I consider it the one punch knock out walk off... place the tube and let the nurses worry about listening. I know it's in and just use standard depths based on gender and size.

Ultrasound to check? C'mon get the f outta here... why not use MRI

 

[thegenius]

You guys do realize that probably 95% of us are producing COVID-19 antibodies by now.

nah. That is way too high

 

[Tiger26]

I consider it the one punch knock out walk off... place the tube and let the nurses worry about listening. I know it's in and just use standard depths based on gender and size.

Ultrasound to check? C'mon get the f outta here... why not use MRI

I did an ultrasound fellowship and I find checking tube position with the ultrasound completely ridiculous unless you're in the back of a helicopter with no end tidal or video laryngoscopy and suck at intubating.

Agree with the above--might as well get an MRI

 

[RoyBasch]

My protocol for possible/confirmed COVID 19 intubations.

No bagging.

Continuous EtCO2 and pulse ox to confirm placement (EtCO2 with good waveform and reading above 30 makes me 95% sure, if the pulse ox is good after several minutes, I'm 100% confident I'm in the trachea). All intubations done with glideoscope, so confidence is pretty high to begin with.

One CXR post intubation both diagnostically and to confirm depth of placement. No auscultation whatsoever. I do not take my stethoscope in the room.

Intubate with PAPR hood worn over N95 mask, lab goggles, wear disposable sterile surgical gown with sterile gloves over regular gloves under the gown.

For non-critical potential COVIDs No auscultation whatsoever at this point. Too much risk I'll contaminate my face touching the ear pieces of my stethoscope to take it in and out of my ears. If patient has a history of asthma/COPD i'll order empiric beta agonist MDIs. Not ideal, but were in a new normal now.

 

[BAM!]

You don’t know how much **** I got a week ago from saying exactly that. Nothing that I hear with my ears is going to trump what I see with my eyes on the capnograph.

who gave you a hard time?

 

[BAM!]

I don't see the point of stethescope. Just put the balloon 1-2 cm past the cords to avoid a mainstem tube.

 

[RustedFox]

I don't see the point of stethescope. Just put the balloon 1-2 cm past the cords to avoid a mainstem tube.

Just insert a rectal airway. You're good to go.

 

[Janders]

Yeah guys... I’ve done a bunch of these. In PAPR. There is no roll for a stethoscope within 20yds of the room.

no color metric. No bagging.

Hard rsi, high dose paralytic pushed first, Straight to vent, wave form capnography.

watch your initial vent settings. If you have it immediately pushing tiny volumes like 6mL/kg TV based on IBW they will de recruit and become hypoxic. start with a bigger TV and wean them down. Keep them sedated hard too (i like to push ketamine and vec once then tube is in, buys time to get real sedation going). Having them desychronous and bucking is a recipe for disaster.

my stethoscope hasn’t left my office in a month.

 

[WheezyBaby]

Personally, I'm a holdout on auscultation--I still find it clinically useful. How else are you going to detect bronchospasm?

But I've never found it useful for tube placement. I think it hurts more than it helps.

Vent waveforms

 

[Groove]

I auscultate more to make sure I'm not mainstemmed. I don't like to put it barely through the cords because the tube can pop out when they are moving the pt on the CT table, etc.. If it sounds deep, I pull it back 1-2 cm. Plus, when you hand the ETT to respiratory, sometimes they aren't exactly precise on taping the ETT in place. Even during a code last week when we got ROSC, I get called back into the room because the pt had coded again. Resp had them on the vent and the pt was clearly cyanotic. I told her to trigger a breath and auscultated the chest, then I told her to disconnect and bag because there was zero air movement until she started bagging. Got ROSC again and explained that the pt had coded again because her damn vent wasn't delivering breaths. If she had bagged and there was still no air movement on auscultation, I would have assumed the ETT got dislodged and re-intubated.

I can't believe we're talking about the uselessness or usefulness of stethoscopes, lol. That's COVID for you. I'm sure we'll have some FOAMed articles soon enough about how there's no benefit to touching a pt or getting any closer to them than the doorway of the room. Unfortunately, I'm just too old and set in my ways.

As for the US being used for placement. Man, I think that method is for the birds. I'm ARDMS and not exactly unskilled with POCUS but even I get confused and frustrated trying to use that method. Actually, there's two methods. One slides to the side and attempts to visualize esophagus or posterior acoustic shadowing from ETT placement in the esophagus and the other is looking for a "double tract sign" through the cricothyroid membrane. Both are anything but easy and the images are difficult to interpret under pressure. If there's loads of vomit, blood or air in the posterior pharynx and upper esophagus or they have a dobhoff, etc.. forget about it.

Don't we have those wireless digital stethoscopes these days? They pop up on my instagram from time to time. You guys who don't auscultate should just get one of those and pop in some AirPods. I don't think you ever have to put the actual stethoscope in your ears.

 

[WheezyBaby]

I auscultate more to make sure I'm not mainstemmed. I don't like to put it barely through the cords because the tube can pop out when they are moving the pt on the CT table, etc.. If it sounds deep, I pull it back 1-2 cm. Plus, when you hand the ETT to respiratory, sometimes they aren't exactly precise on taping the ETT in place. Even during a code last week when we got ROSC, I get called back into the room because the pt had coded again. Resp had them on the vent and the pt was clearly cyanotic. I told her to trigger a breath and auscultated the chest, then I told her to disconnect and bag because there was zero air movement until she started bagging. Got ROSC again and explained that the pt had coded again because her damn vent wasn't delivering breaths. If she had bagged and there was still no air movement on auscultation, I would have assumed the ETT got dislodged and re-intubated.

I can't believe we're talking about the uselessness or usefulness of stethoscopes, lol. That's COVID for you. I'm sure we'll have some FOAMed articles soon enough about how there's no benefit to touching a pt or getting any closer to them than the doorway of the room. Unfortunately, I'm just too old and set in my ways.

As for the US being used for placement. Man, I think that method is for the birds. I'm ARDMS and not exactly unskilled with POCUS but even I get confused and frustrated trying to use that method. Actually, there's two methods. One slides to the side and attempts to visualize esophagus or posterior acoustic shadowing from ETT placement in the esophagus and the other is looking for a "double tract sign" through the cricothyroid membrane. Both are anything but easy and the images are difficult to interpret under pressure. If there's loads of vomit or blood in the posterior pharynx and upper esophagus or they have a dobhoff, etc.. forget about it.

Don't we have those wireless digital stethoscopes these days? They pop up on my instagram from time to time. You guys who don't auscultate should just get one of those and pop in some AirPods. I don't think you ever have to put the actual stethoscope in your ears.

Lung auscultation is one of the physical exams I'm a believer in, but it's another source of cross contamination in these patients unless using one of the cheap disposables, not sure it's worth it. I don't use tracheal ultrasound, but could also do POCUS on b/l lung fields as a short term measure if you're lining someone up before Xray comes by.

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