Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 05 13 1446 1446 Behzad Nazemroaya Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Azim Honarmand Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Sedighe Shahhosseini Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Erfan Roghaei Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. 2025 10 12 2025 10 21 Background: Accurate confirmation of endotracheal tube (ETT) placement is essential to ensure adequate ventilation and prevent life-threatening complications in pediatric anesthesia. Traditional methods such as auscultation and capnography have inherent limitations. Point-of-care ultrasound (POCUS) has recently emerged as a rapid and reliable alternative. This study aimed to compare the diagnostic accuracy of ultrasound and finger palpation for ETT placement confirmation in children undergoing general anesthesia. Methods: In this diagnostic accuracy clinical trial, 60 children aged 3–6 years (ASA I–II) scheduled for elective surgery were enrolled. Following standardized tracheal intubation, both ultrasound and finger palpation were performed sequentially by independent blinded operators. Fiberoptic bronchoscopy served as the reference standard. Diagnostic indices, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated. Secondary outcomes included operator confidence (5-point Likert scale) and time to confirmation. Results: Ultrasound achieved higher sensitivity (92.5%) and specificity (71.4%) compared with finger palpation (79.2% and 100%, respectively). The PPV and NPV for ultrasound were 96.1% and 55.6%, whereas those for palpation were 100% and 38.9%. Operator confidence was significantly greater with ultrasound (4.37 ± 0.74) than with palpation (3.45 ± 1.03; p < 0.001). The mean confirmation time was also shorter using ultrasound (16.12 ± 1.55 s) than palpation (20.95 ± 1.88 s; p < 0.001). No complications occurred. Conclusion: Tracheal ultrasonography provides a rapid, highly sensitive, and non-invasive way of verifying the proper placement of the endotracheal tube (ETT) in children, which is much more accurate and rapid than finger palpation. While finger palpation is a simple bedside technique with an ideal specificity, its low sensitivity makes it less useful as a sole diagnostic tool. The incorporation of ultrasonography into the usual management of the pediatric airway may have the potential of enhancing patient safety. https://aacc.tums.ac.ir/index.php/aacc/article/view/1446