Gastric Carbon Dioxide Insufflation Can Lead to Misleading Capnography Trace During Esophageal Intubation

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*

“…Preventable mortality and serious morbidity from unrecognised oesophageal intubation continue to occur worldwide [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ], despite existing guideline recommendations and widely publicised education programmes [ 31 ] .…”

“…While oesophageal intubation is typically associated with the absence of any detected carbon dioxide (i.e. ‘no trace’), many fatal cases involve confusion over deteriorating, inadequate or grossly abnormal carbon dioxide detection [ 9 , 10 , 12 , 30 ]. This guideline therefore provides unambiguous criteria for sustained exhaled carbon dioxide that if not met, empower teams to initiate the actions outlined below.…”

“…Failure to satisfy the criteria for sustained exhaled carbon dioxide following passage of a tracheal tube therefore requires oesophageal intubation to be actively excluded [ 8 , 71 , 72 , 73 , 74 , 75 , 76 , 77 ]. Although in some circumstances exhaled carbon dioxide may be detected despite oesophageal intubation (Table 2 [ 12 , 91 , 95 , 96 , 97 ]), even these false positives will not typically result in sustained exhaled carbon dioxide. In rare situations, the first three criteria may be satisfied despite the tube being misplaced (e.g.…”

“…Furthermore, oesophageal intubation was not detected when repeat laryngoscopy was performed by the practitioner who performed the initial intubation, in any of the cases reviewed for this guideline [ 15 , 28 , 30 ]. In contrast, repeat laryngoscopy by a different operator often detected oesophageal intubation [ 10 , 12 , 15 , 28 , 30 ].…”

“…Occurrences may only be highlighted by coronial or media reports, and it is likely not all cases are reported. The number of these reports in recent years clearly indicates that preventable events occur regularly and are an international problem [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. In the 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and Difficult Airway Society, nine cases of unrecognised oesophageal intubation were reported [ 42 , 43 ]: three during anaesthesia for surgery, four in the intensive care unit (ICU) and two in emergency departments.…”