Abstract
Unrecognized misplacement of the endotracheal tube (ETT) during endotracheal intubation and ventilation, has a reported incidence of 2.9%–16.7% and is a frequent cause of morbidity and mortality in emergency intubations. Accidental esophageal intubation is a common mistake in inexperienced anesthetists, but unrecognized esophageal intubation is, fortunately, a rare event because, in anesthetic malpractice claims, it frequently resulted in death or brain damage. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings.
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