Accidental Oesophageal Intubation Research Articles

Comparison between ultrasonography and capnography for ascertaining placement of endotracheal tube in patients undergoing general anesthesia – A prospective observational study

Background: Confirmation of the position of the endotracheal tube (ETT) is an essential step for verification of intubation. Failure to diagnose esophageal intubation may lead to fatal consequences. Capnography is the gold standard for confirmation of ETT position, but it is practically impossible to be performed in all situations. Ultrasonography (USG) or “visual stethoscope” can be used as an effective alternative for all intubators in all situations. Aims and Objectives: The study was conducted to evaluate the ultrasonography (USG) technique with respect to its efficacy to detect the proper endotracheal position of ETT compared to end-tidal capnography among patients undergoing general anesthesia; to compare the time taken by the USG technique with that of capnography for detection of proper placement of ETT; to assess the feasibility of USG to detect accidental esophageal intubation. Materials and Methods: This prospective comparative cross-sectional observational study was conducted on 68 patients. Both capnography and upper airway USG were performed immediately after intubation to confirm the ETT placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. The time required to determine ETT placement by the two methods was found out and compared. Agreement between the methods was assessed with kappa statistics. Results: USG detected all three cases of esophageal intubation but could not detect two patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.92% (95% confidence interval [CI]: 93.54–100%), specificity of 100%, positive predictive value of 100%, and negative predictive value of 60% (95% CI: 50.4–69.6%). The Kappa value was found to be 0.735, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 21.68±2.63 s versus 11.44±1.38 s for upper airway USG (P<0.001). USG demonstrated bilateral lung sliding in 60 (88.2%) patients, unilateral lung sliding in 3 (4.4%) patients, and lung sliding was absent in 5 (7.4%) patients. Conclusion: Real-time upper airway USG is an alternative method of confirmation of ETT that is not only sensitive and accurate but is faster than the current gold standard method, capnography.

Gastric Perforation, a Rare Consequence of Unintentional Esophageal Intubation

Accidental esophageal intubation is a preventable human error that complicates airway management and continues to occur despite advances in medical devices. Perforation of the stomach has been associated with esophageal intubation in several case reports. This report presents a case of an elderly woman suspected of having COVID-19-related pneumonia. She was intubated due to respiratory dysfunction. In the initial few minutes, the patient became desaturated, leading to a second intubation. An hour later, the patient’s abdomen was distended, and the chest computed tomography (CT) showed a massive pneumoperitoneum. During laparotomy, a 6 cm long rupture was found in the lesser curvature, which was attributed to accidental esophageal intubation. To avoid such a fatal condition, it is imperative for physicians to ensure the correct positioning of the endotracheal tube. To achieve this goal, further investigation into readily available and highl y sensitive techniques is recommended.

Endotracheal tube-mounted camera-assisted intubation versus conventional intubation in intensive care: a prospective, randomised trial (VivaITN)

BackgroundFor critically ill patients, effective airway management with a high first-attempt success rate for endotracheal intubation is essential to prevent hypoxic complications during securing of the airway. Video guidance may improve first-attempt success rate over direct laryngoscopy (DL).MethodsWith ethics approval, this randomised controlled trial involved 54 critically ill patients who received endotracheal intubation using a tube with an integrated video camera (VivaSight™-SL tube, VST, ETView Ltd., Misgav, Israel) or using conventional intubation under DL.ResultsThe two groups did not differ in terms of intubation conditions. The first-attempt success rate was VST 96% vs. DL 93% (not statistically significant (n. s.)). When intubation at first attempt failed, it was successful in the second attempt in all patients. There was no difference in the median average time to intubation (VST 34 s (interquartile range 28–39) vs. DL 35 s (28–40), n. s.). Neither vomiting nor aspiration or accidental oesophageal intubation were observed in either group. The lowest pulsoxymetric oxygen saturation for VST was 96 (82–99) % vs. 99 (95–100) % for DL (n. s.). Hypotension defined as systolic blood pressure < 70 mmHg occurred in the VST group at 20% vs. the DL group at 15% (n. s.).ConclusionIn this pilot study, no advantage was shown for the VST. The VST should be examined further to identify patient groups that could benefit from intubation with the VST, that is, patients with difficult airway conditions.Trial registrationClinicalTrials.gov, NCT02837055. Registered on 13 June 2016.

WITHDRAWN: Techniques to ascertain correct endotracheal tube placement in neonates.

The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. We did not identify any studies meeting the criteria for inclusion in this review. There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.

Delayed detection of esophageal intubation: Nasogastric tube was the cause?

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.

Techniques to ascertain correct endotracheal tube placement in neonates.

The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. We did not identify any studies meeting the criteria for inclusion in this review. There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.

Gastric perforation after accidental esophageal intubation in a patient with deep neck infection

Deep neck infection with airway obstruction may complicate endotracheal intubation with limited neck motion, pharyngeal swelling, and prominent secretion. Unrecognized esophageal intubation (EI) may unduly overinflate the stomach to inhibit effective ventilation, increase the incidence of hypoxia, and produce a ruptured visceral organ. We report an 81-year-old female patient with deep neck infection and impending respiratory failure who suffered gastric perforation after accidental EI in the intensive care unit. After failed attempts of intubation, EI was recognized rapidly as the culprit, although roughly audible bilateral breathing sounds were present but not gastric bubble sounds. A catastrophic complication of gastric rupture occurred due to ambu-bagging and mechanical ventilation. Surgical intervention was performed immediately. Possible mechanisms are discussed.

Novel method to confirm tracheal intubation based on airway pressures: validation in patients with lung disease

Emergency endotracheal intubation results in accidental oesophageal intubation in up to 17% of patients often with disastrous consequences. We have previously published a highly specific and sensitive novel method to detect endotracheal intubation based on differences in ventilation pressure waveforms in the oesophagus and in the trachea in patients with healthy lungs [1]. A detection algorithm, based on differences in compliance/elasticity between the lung and the oesophagus, generated a D-value indicating tracheal intubation if D >0.5 and oesophageal intubation if D <0.5. The aim of the current study was to validate the algorithm in patients with lung disease.

A novel method to detect accidental oesophageal intubation based on ventilation pressure waveforms

a b s t r a c t Background: Emergency endotracheal intubation results in accidental oesophageal intubation in up to 17% of patients. This is frequently undetected thereby adding to the morbidity and mortality. No current method to detect accidental oesophageal intubation in an emergency setting is both highly sensitive and specific. We hypothesized that, based on differences between the mechanical properties of the oesoph- agus and the trachea/lung, ventilation pressures could discriminate between tracheal and oesophageal intubation. Such a technique would potentially not suffer some of the limitations of current methods to detect oesophageal intubation in emergency conditions such as noisy environment (making clinical assessment difficult) or low/no flow states (reducing the applicability of capnometry). The aim of our study was thus to develop and assess a technique that may more rapidly and accurately differentiate oesophageal from tracheal intubation based on airway pressure gradients. Materials and methods: Forty adult patients undergoing elective surgery were included. In 20 patients the trachea was intubated with an endotracheal tube; in 20 patients the oesophagus was purposefully intubated using an Easytube ® (Rush, Germany). In all patients, a thin air-filled catheter was inserted through the tube lumen until its tip was 1 cm from the distal end, and connected to a pressure transducer. Pressure was recorded simultaneously from a second catheter at the proximal end of the tube. For the first three manual ventilations in each patient, a parameter (D) based on temporal (dP/dt) and spatial (dP/ds) pressure gradients (and reflecting flow divided by elastance) was calculated and evaluated for its ability to discriminate between oesophageal and tracheal intubation. Results and discussion: For all tracheal ventilations, D-values were >0.5 (range 0.6-47.9), while for all oesophageal ventilations D-values were <0.5 (range 0.0005-0.07). Conclusion: This technique has the potential to provide a diagnosis of failed intubation within seconds with high sensitivity and specificity. © 2011 Elsevier Ireland Ltd. All rights reserved.

Adverse Events Much More Likely with Repeated Intubation Attempts

The incidence of adverse events tripled when a second attempt was needed. To determine the association between adverse events and number of endotracheal intubation attempts, researchers reviewed standardized data collected from 1828 orotracheal intubations performed at an academic emergency department during 4 years. Almost all of the intubations (98%) were by performed by trainees, mostly second- and third-year emergency medicine residents. Adverse events were defined as accidental extubation, aspiration, cardiac arrest, cuff leak, dental trauma, dysrhythmia, esophageal intubation, hypotension (decrease in systolic blood pressure <90 mm Hg), laryngospasm, mainstem intubation, oxygen desaturation (decrease in oxygen saturation 10%), and pneumothorax. Intubation was successful on the first attempt in 73% cases and in two or more attempts in the remainder. The incidence of adverse events increased with the number of attempts: 14%, 47%, 64%, and 71% with one, two, three, and four or more attempts, respectively. The most common adverse events in patients requiring multiple attempts were oxygen desaturation (38%), esophageal intubation (16%), aspiration (6%), and mainstem intubation (4%).

Improving Assessment During Noninvasive Ventilation in the Delivery Room

The efficacy of mask ventilation has traditionally been judged by evaluating clinical signs alone (eg, assessment of heart rate, chest movements, skin color), which can be misleading. Despite the recent introduction of extended noninvasive monitoring, neonatal resuscitation remains challenging. This article discusses the current evidence on clinical assessment and monitoring during noninvasive mask ventilation in the delivery room. Potential pitfalls during mask ventilation are discussed, which may be identified with structured neonatal resuscitation courses, video recording, or extended physiological monitoring. Successful placement of a correctly positioned endotracheal tube by junior medical staff is &amp;lt;50%, and accidental esophageal intubation is common. Clinical signs are subjective and can be misleading, and recognition of esophageal placement of the endotracheal tube, by using clinical assessment alone, can take up to several minutes. Because carbon dioxide is exhaled at much higher concentrations than inhaled, it can be detected with semiquantitative colorimetric devices, or devices that display numeric or graphic values. In the section on carbon dioxide detectors, the current evidence (along with limitations) concerning these devices is discussed.

A novel method to detect accidental oesophageal intubation based on ventilation pressure waveforms

BackgroundEmergency endotracheal intubation results in accidental oesophageal intubation in up to 17% of patients. This is frequently undetected thereby adding to the morbidity and mortality. No current method to detect accidental oesophageal intubation in an emergency setting is both highly sensitive and specific. We hypothesized that, based on differences between the mechanical properties of the oesophagus and the trachea/lung, ventilation pressures could discriminate between tracheal and oesophageal intubation. Such a technique would potentially not suffer some of the limitations of current methods to detect oesophageal intubation in emergency conditions such as noisy environment (making clinical assessment difficult) or low/no flow states (reducing the applicability of capnometry). The aim of our study was thus to develop and assess a technique that may more rapidly and accurately differentiate oesophageal from tracheal intubation based on airway pressure gradients. Materials and methodsForty adult patients undergoing elective surgery were included. In 20 patients the trachea was intubated with an endotracheal tube; in 20 patients the oesophagus was purposefully intubated using an Easytube® (Rüsh, Germany). In all patients, a thin air-filled catheter was inserted through the tube lumen until its tip was 1cm from the distal end, and connected to a pressure transducer. Pressure was recorded simultaneously from a second catheter at the proximal end of the tube. For the first three manual ventilations in each patient, a parameter (D) based on temporal (dP/dt) and spatial (dP/ds) pressure gradients (and reflecting flow divided by elastance) was calculated and evaluated for its ability to discriminate between oesophageal and tracheal intubation. Results and discussionFor all tracheal ventilations, D-values were >0.5 (range 0.6–47.9), while for all oesophageal ventilations D-values were <0.5 (range 0.0005–0.07). ConclusionThis technique has the potential to provide a diagnosis of failed intubation within seconds with high sensitivity and specificity.

A novel method to detect accidental oesophageal intubation based on ventilation pressure waveforms

a b s t r a c t Background: Emergency endotracheal intubation results in accidental oesophageal intubation in up to 17% of patients. This is frequently undetected thereby adding to the morbidity and mortality. No current method to detect accidental oesophageal intubation in an emergency setting is both highly sensitive and specific. We hypothesized that, based on differences between the mechanical properties of the oesoph- agus and the trachea/lung, ventilation pressures could discriminate between tracheal and oesophageal intubation. Such a technique would potentially not suffer some of the limitations of current methods to detect oesophageal intubation in emergency conditions such as noisy environment (making clinical assessment difficult) or low/no flow states (reducing the applicability of capnometry). The aim of our study was thus to develop and assess a technique that may more rapidly and accurately differentiate oesophageal from tracheal intubation based on airway pressure gradients. Materials and methods: Forty adult patients undergoing elective surgery were included. In 20 patients the trachea was intubated with an endotracheal tube; in 20 patients the oesophagus was purposefully intubated using an Easytube ® (Rush, Germany). In all patients, a thin air-filled catheter was inserted through the tube lumen until its tip was 1 cm from the distal end, and connected to a pressure transducer. Pressure was recorded simultaneously from a second catheter at the proximal end of the tube. For the first three manual ventilations in each patient, a parameter (D) based on temporal (dP/dt) and spatial (dP/ds) pressure gradients (and reflecting flow divided by elastance) was calculated and evaluated for its ability to discriminate between oesophageal and tracheal intubation. Results and discussion: For all tracheal ventilations, D-values were >0.5 (range 0.6-47.9), while for all oesophageal ventilations D-values were <0.5 (range 0.0005-0.07). Conclusion: This technique has the potential to provide a diagnosis of failed intubation within seconds with high sensitivity and specificity. © 2011 Elsevier Ireland Ltd. All rights reserved.

CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation

Rupture of the oesophagus or stomach at the time of cardiopulmonary resuscitation can occur with accidental oesophageal intubation. The common site of rupture is the lesser curvature of the stomach,...

The use of impedance respirometry to confirm tracheal intubation in children

Accidental oesophageal intubation can occur in children and is a cause of morbidity and mortality. This study investigated the use of impedance respirometry to determine tracheal tube position in children aged 1-10 years. Eighty children were recruited and, after induction of anaesthesia, two identical tracheal tubes were inserted: one into the trachea and one into the oesophagus. The breathing system was attached to one of the tubes chosen at random. A blinded observer was asked to identify the position of the tube within six breaths using impedance respirometry. The positions of 76 out of 80 tubes were correctly identified. Of those incorrectly identified, one was in the trachea and three were in the oesophagus. The sensitivity of the test was 0.975 and the specificity 0.925. The median number of breaths needed to identify the position of the tubes was 2.0 for both groups. This is not a perfect technique in the population studied but when used with other methods of tracheal tube position identification, its use could decrease the time taken to identify incorrect placement.

Total Airway Obstruction by a Mucous Plug Relieved With Extreme Positive Pressure: Case Report of a Pediatric Patient*1

Tracheal intubation can be a stressful procedure, especially when performed in emergency situations. The introduction of a colorimetric device to detect the presence of exhaled carbon dioxide (co2) has strengthened the assurance that the endotracheal tube (ETT) has been correctly placed. 1. Grmec S Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 2002; 28: 701-704 Crossref PubMed Scopus (206) Google Scholar , 2. Ornato JP Shipley JP Racht EM Stovis CM Wrenn KD Pepe PE et al. Multicenter study of a portable, hand size colorimetric end tidal carbon dioxide detection device. Ann Emerg Med. 2001; 20: 223-229 Google Scholar Bilateral equal breaths sounds, moisture in the ETT, visible chest rise, and visualization of the tube passing the vocal cords are important but have not been 100% reliable. Breath sounds can be transmitted to the chest from the esophagus, moisture from the esophagus can be seen in the tube, gastric air can seem to move the chest, and even though the operator claims the tube passed between the cords, sometimes the tube is deflected posteriorly into the esophagus. 3. Clyburn P Rosen M Accidental oesophageal intubation. Br J Anesth. 1994; 73: 55-63 Crossref PubMed Scopus (58) Google Scholar , 4. Andersen KH Schultz-Lebahn T Oesophageal intubation can be undetected by auscultation of the chest. Acta Anesthesiol Scand. 1994; 38: 580-582 Crossref PubMed Scopus (52) Google Scholar , 5. Haridas RP Condensation of tracheal tubes is commonly seen with oesophageal intubation. Br J Anesth. 1995; 75: 115-116 Abstract Full Text PDF PubMed Scopus (6) Google Scholar It appears that the presence of exhaled co2 is the sine quo non evidence of tracheal intubation. CorrectionJournal of Emergency NursingVol. 30Issue 6PreviewAngela T. Zimmerman, MD, Assistant Professor, Department of Anesthesiology and Perioperative Medicine, should have been listed as the last author in the October 2004 Clinical Notebook article: Shoun P, Steelman R, Barber B, Olson M, Pate MFD. Total airway obstruction by a mucous plug relieved with extreme positive pressure: Case report of a pediatric patient. 2004;30:473-4. Full-Text PDF

Detection and Correction of Accidental Oesophageal Intubation during Flexible Lightwand-Guided Intubation via the Intubating Laryngeal Mask

In the following two-part study, we determined the efficacy of observation of the light glow to detect correct placement of the tracheal tube after lightwand-guided tracheal intubation via the intubating laryngeal mask (ILM). We also determined the efficacy of a protocol to correct oesophageal intubation in this situation. In study 1, 80 ASA 1-3, anaesthetized, paralysed patients were randomly assigned to have a tracheal tube, preloaded with a flexible lightwand, placed into either the trachea (n=40) or oesophagus (n=40) under laryngoscope guidance. A blinded observer experienced with the lightwand technique determined whether oesophageal or tracheal intubation had occurred by observation of the light glow. In study 2, 1,000 patients, 400 of whom were included in a previous study, underwent flexible lightwand-guided intubation via the ILM. Placement of the tracheal tube in oesophagus or trachea was determined by observation of the glow and verified by capnography. Oesophageal intubation was corrected by adjusting the ILM position using a protocol comprising two adjusting manoeuvres. Observation, verification and correction were by experienced anaesthetists conducting the case. In study 1, oesophageal and tracheal intubation was correctly detected in 38/40 (95%) and 37/40 (92.5%) patients respectively. In study 2, oesophageal and tracheal intubation was correctly detected in 55/55 (100%) and 945/945 (100%) patients respectively. In 40/55 (73%) patients, tracheal intubation was successful at the second attempt and in 13/55 (24%) at the third or fourth attempt. In 2/55 (4%) patients, persistent oesophageal intubation occurred. The sensitivity, specificity and positive predictive value were 95%, 92.5% and 92.7% respectively in study 1, and were all 100% in study 2.

Review And New Use For The Univent Tube

The univent tube has been used maily for one lung anesthesis.There are other clincal settings where the tube was found to be useful. The univent tube can be used in cases of difficult intubation while supplimenting oxygen and monitoring ETCO2. Macintosh first used the gum-elastic bougie as an aid to intubation in 1943 when he found that the tracheal tube could obstruct his view of the cords. The lubricated gum elastic catheter was therefore first threaded through the tube and then gently placed into the trachea. The tube was pushed down into the trachea over the catheter and the catheter removed. The technique was also used when exposure of the larynx was inadequate [ 1]. The technique is now commonly advocated when the cords cannot be seen at laryngoscopy. The catheter briefly retains the approximate shape into which it is bent. It is important to keep the catheter in the midline and to bend the distal end forward after it has been passed through the tracheal tube. The catheter can then be advanced blindly towards the cords and the tube then 'railroaded' over the catheter. It is necessary to check very carefully that the tube has passed into the trachea. In addition to listening to the chest and observing chest movement it is mandatory to listen over the stomach and if possible to measure expired carbon dioxide levels to exclude accidental esophageal intubation.

Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation

This analysis primarily sought to determine the effectiveness of end-tidal capnography for tube placement confirmation during emergency airway management. Secondary objectives were validation of the rate of unanticipated esophageal placement during emergency intubation and quantification of the portion of intubations performed in patients with cardiac arrest where capnography is not recommended. The study was performed in two phases. For the primary objective, a meta-analysis was performed on all experimental capnography trials enrolling emergency populations. For the secondary objectives, inadvertent esophageal intubation and cardiac arrest rates were calculated from a large prospective multicenter observational study of emergency intubation cases. Data analysis included calculation of descriptive statistics, sensitivity, specificity, and confidence intervals (CI). Based on 2,192 intubations, a meta-analysis of previous capnography trials resulted in an aggregate sensitivity of 93% (95% CI 92–94%) and an aggregate specificity of 97% (CI 93–99%) for emergency tube placement confirmation. Thus, for emergency capnography use, the false-negative failure rate (tube in trachea but capnography reports esophagus) was 7% and the false-positive rate (tube in esophagus but capnography reports trachea) was 3%. This translates to potential harm for one patient in every 10 treated with capnographic confirmation alone (number needed to harm: 14 for false-negative, 33 for false-positive, and 10 for both). A further literature review demonstrated no sole method of tube placement confirmation is completely foolproof. Of 4,602 consecutive intubations reported to the National Emergency Airway Registry, 4% of emergency intubation attempts resulted in accidental esophageal intubation, and 10% occurred in nontraumatic cardiac arrest patients. During tracheal intubation of critically ill patients, it is concluded that the rate of accidental esophageal tube placement warrants continued improvement in emergency airway techniques. Misidentification of esophageal placement in the emergency setting may occur with capnography. Multiple methods of tube placement confirmation are superior to any single method because no single method has perfect accuracy.

Incidence of accidental oesophageal intubation during light-guided intubation via the intubating laryngeal mask

Incidence of accidental oesophageal intubation during light-guided intubation via the intubating laryngeal mask