“We Hear What You Are Saying, but…”

We read with interest as Ramsingh et al.¹  described their study comparing the efficacy of point-of-care ultrasound versus auscultation by using a stethoscope in determining proper endotracheal/bronchial positioning. We have used ultrasound to answer questions about endotracheal tube placement, possible pneumothorax, and difficult airway anatomy—all of which have been well-described by Kristensen.²  Clearly, ultrasound offers advantages in very specific situations. We applaud the authors for describing a new technique in confirming the laterality of bronchial intubation. The authors rightly recognize the limitations of their study, especially the fact that auscultation and ultrasound were compared in isolation. In the actual clinical setting of other monitors including capnography, peak airway pressures, observation of chest excursion, and endotracheal tube humidification, it is hard to imagine that the addition of ultrasonography offers any significant advancement in patient safety for the following reasons: first, the authors state that the technique is “quick,” which is then defined as “less than 4 min.” In terms of airway management, 4 min strikes us as a long time. Depending on habitus and other pulmonary pathologies, the safe apneic time of a given patient may preclude ultrasound examination. Second, ultrasound is expensive, and availability is a legitimate concern. Even though we are employed in a large academic center that has many portable ultrasounds, the demand frequently exceeds the supply of devices. Third, compared to a stethoscope, ultrasounds are currently more cumbersome, breakable, and energy-source dependent. Fourth, ultrasounds do not fill every role our stethoscopes play; for example, they cannot diagnose bronchospasm or flash pulmonary edema.

In summary, while we respect the application of this technology, we do not yet see how it can be a point-of-care device in a clinical practice in the described manner. The authors suggest that the stethoscope is outdated. We believe that their technique (especially if larger studies demonstrate similar sensitivity and specificity) needs consideration for adoption, but faulting a device merely because of its age is fallacious. Lewis³  called this “chronological snobbery,” the assumption that newer must be better. We would be wise to remember that the development of a new technique does not require the elimination of an older one. The more conscientious anesthesiologist will recognize the advantage of having both tools available.

The authors declare no competing interests.