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Objective To compare protocolised airway and thoracic ultrasound with conventional methods for confirmation of endotracheal intubation and positioning in critically ill children.Design Open label randomised controlled trial.Setting Department of paediatric critical care at a tertiary care hospital.Participants Patients (1 month–18 years) admitted to paediatric intensive care unit requiring endotracheal intubation.Interventions Children were randomised to protocolised airway and thoracic ultrasound (USG) group (group A) or conventional group (group B). In group A, ultrasound-guided endotracheal tube (ETT) placement was performed. Subsequently, adequate bilateral lung ventilation was confirmed by the presence of lung sliding by using ultrasound. In group B, ETT placement in the trachea was confirmed by capnography and auscultation of the chest. The position of the ETT was confirmed by chest X-ray in both the groups.Main outcome measures The primary outcome was the detection of ETT malposition and oesophageal intubation. Key secondary outcomes included the time taken to detect ETT placement and complications observed during intubation.Results A total of 201 children were enrolled and randomised, 101 in group A(Ultrasound) and 100 in group B(conventional). The median (IQR) age was 72 (24, 168) months for USG group and 60 (10, 134) months in conventional group (p=0.37). The incidence of ETT malposition was significantly higher in group B compared with group A (45.0% vs 26.7%) (risk ratio (RR) 0.46; 95% CI 0.23 to 0.94; p=0.033). The incidence of oesophageal intubation was 4.9% in group A (n=5) and 13.0% in group B (n=13) (p=0.038). Mean time taken (s) to detect tube placement in group A was less than group B (21.1 vs 27.3) (RR 5.5; 95% CI 4.01 to 7.04; p<0.001). Complications, such as hypoxia and bradycardia, was lesser in USG group as compared to other group.Conclusion Airway and thoracic ultrasound reduces the incidence of ETT malposition, and it rapidly detects endotracheal tube placement in the trachea.