Confirmation and reproducibility of endotracheal tube position by tracheal ultrasonography in preterms: expert versus trainee

Tracheal intubation (TI) is critical in neonatal intensive care and delivery rooms, requiring precise placement of the endotracheal tube (ETT) to prevent complications. Various methods confirm ETT position; whilst chest radiography remains standard for identifying ETT depth, ultrasonography (USG) shows promise as a real-time, radiation-free alternative. That is why we aimed to evaluate the concordance between tracheal ultrasound (TUS) and chest x-ray to identify the depth of the ETT in the trachea in preterm neonates and to compare the reproducibility of TUS done by a trainee neonatologist and an expert radiologist. This cross-sectional study involved 85 preterm infants who had an ETT. Tracheal ultrasonography was performed by a neonatologist (who had been trained in chest ultrasonography for 3 months) and repeated by an expert radiologist. Operators were blinded to the radiographic results. The overall agreement was good, with near-complete concordance for ETT localization at the 2nd intercostal space across techniques: 89.4% (PSA 93.5%) between expert TUS and CXR, 82.4% (PSA 89.1%) between trainee TUS and CXR, and 89.1% (PSA 92.3%) between expert and trainee TUS. Conclusion : Bedside tracheal ultrasonography is a reliable, fast, safe, and effective method for assessing endotracheal tube position in the NICU. With adequate training, neonatologists can perform the procedure independently which speeds up ETT position confirmation. Trial registration : The clinical trial was retrospectively registered on clinical trials.gov 7/17/2025. CLINICALTRIALS.GOV ID: NCT07073105. https://CLINICALTRIALS.GOV/STUDY/NCT07073105 . What is Known: • Improper endotracheal tube (ETT) placement and depth in the trachea can cause severe complications. • Chest X-ray is used for the identification of ETT depth in the trachea but causes delays and radiation exposure. What is New: • Tracheal ultrasound offers rapid, radiation-free confirmation. • With brief training, a neonatology trainee achieved agreement with an expert radiologist in identifying the depth of ETT in the trachea in preterm infants.