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

Abstract

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Keywords: airway management; capnography; human factors; oesophageal intubation; tracheal intubation.

Figure 1

Glottic impersonation. Blanching of the lateral aspects of the oesophageal opening (below) due to forceful laryngoscopy may lead it to be mistaken for the glottis (above). Careful attention by an experienced practitioner should enable the oesophageal and glottic openings to be distinguished. However, confusion may be more likely when intubation is challenging, with the potential combination of one or more of excessively deep blade insertion, aggressive laryngoscopy, time pressure, expectation of seeing the larynx, impaired decision‐making and a restricted view that does not reveal the larynx above (see box). Photo reproduced from original publication in Canadian Journal of Anesthesia [49] with permission. White box was added for this guideline.

Figure 2

Criteria for ‘sustained exhaled carbon dioxide’. This graphic has been designed to be used as both a foundation tool to be reviewed in advance of clinical use and an implementation tool to be referred to in real time during clinical practice [93]. A high‐resolution version of this graphic is available for download at https://www.UniversalAirway.org/downloads. Printing and laminating this at A3 size is recommended.

Figure 3

Algorithm for approaching failure to satisfy the criteria for ‘sustained exhaled carbon dioxide’ following passage of a tracheal tube. This algorithm has been designed to be used as an implementation tool [93], to be referred to in real time during clinical practice. Optimal use during clinical practice requires prior familiarity with the algorithm and guideline text. A high‐resolution version of the algorithm is available for download at https://www.UniversalAirway.org/downloads. Printing and laminating this at A3 size is recommended.

Figure 4

Valid alternative techniques to exclude oesophageal intubation. This graphic has been designed to be used as both a foundation tool to be reviewed in advance of a clinical use and an implementation tool to be used as a real‐time prompt during clinical practice [93]. A high‐resolution version of this graphic is available for download at https://www.UniversalAirway.org/downloads. Printing and laminating this at A3 size is recommended. The photos of the glottis and trachea are clinical cadaver images from Dalhousie University's Human Body Donation Program. Used with permission. Ultrasound images are copyright Gottlieb et al. https://doi.org/10.5811/westjem.2017.12.36714 [111] and licensed under a Creative Commons Attribution 4.0 International License. Text labels and tick/cross‐icons were added for this guideline.

Figure 5

Repeat laryngoscopy in the presence of oesophageal intubation. All tubes pictured are placed in the oesophagus. None meet the visual criteria for excluding oesophageal intubation on repeat laryngoscopy. The boxes (upper row) illustrate how a more restricted view, as might occur with challenging anatomy or use of direct laryngoscopy, could contribute to misinterpretation of the site of tube placement. This is particularly true if the practitioner is time pressured or at risk of confirmation bias. The arytenoids may be mistaken for the epiglottis (a and c), blanching of the lateral aspects of the oesophageal opening (c and f) or the cuff (b) may be mistaken for the vocal cords. The epiglottis may conceal the larynx entirely (D and F). In (e), the right arytenoid is visible lateral to the tube but cannot be confirmed to be passing posterior to it. All photos are clinical cadaver images from Dalhousie University's Human Body Donation Program. Used with permission.

Figure 6

‘Quick Check’ to identify the causes of failure to satisfy the criteria for ‘sustained exhaled carbon dioxide’ other than oesophageal intubation: This graphic is designed to be used as a foundation tool [93], to be reviewed in advance of clinical use, to enable subsequent prompting by the icons on the algorithm (Fig. 3). It is not intended to be referred to in real time during clinical practice. A high‐resolution version of this graphic is available for download at https://www.UniversalAirway.org/downloads.