What are the consequences of unrecognized esophageal intubation (insertion of the endotracheal tube into the esophagus)?

From the Guidelines

Unrecognized esophageal intubation is a life-threatening emergency that requires immediate recognition and correction, and the most reliable method for confirming endotracheal tube placement is end-tidal CO2 detection, as recommended by the 2018 guidelines for the management of tracheal intubation in critically ill adults 1. To prevent this complication, always confirm proper endotracheal tube placement using multiple methods:

• direct visualization of the tube passing through the vocal cords
• chest rise with ventilation
• auscultation of bilateral breath sounds
• absence of gurgling over the stomach
• end-tidal CO2 detection (most reliable method)
• chest X-ray confirmation. Continuous capnography monitoring should be used throughout mechanical ventilation to ensure ongoing proper tube placement, as it can detect 95% of all critical incidents and 67% before potential organ damage has occurred 1. Clinical signs of esophageal intubation include:
• absent or diminished breath sounds
• gurgling over the epigastrium
• cyanosis
• oxygen desaturation
• absence of CO2 detection
• gastric distention. Remember that clinical assessment alone can be unreliable, especially in cardiac arrest situations, so always use waveform capnography when available, as it is essential for reducing the risk of airway-related deaths 1. Proper training in airway management and adherence to verification protocols significantly reduces the risk of this potentially fatal complication, and healthcare providers should maintain their knowledge and skills through frequent practice, as recommended by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. In addition, the use of capnography to confirm and monitor correct placement of endotracheal tubes is crucial, as it can help prevent unrecognized tube misplacement or displacement, and providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement 1. The consequences of unrecognized esophageal intubation can be severe, including severe hypoxaemia, cardiac arrest, and death, as highlighted in the 2017 guidelines for intubation and extubation of the ICU patient 1. Therefore, it is essential to prioritize the use of end-tidal CO2 detection and continuous capnography monitoring to prevent and detect esophageal intubation, and to ensure that healthcare providers are properly trained and equipped to manage airway emergencies.

From the Research

Consequences of Unrecognized Esophageal Intubation

• Unrecognized esophageal intubation can result in anoxic brain injury, cardiac arrest, or death 2
• It is a major cause of harm and death in patients undergoing tracheal intubation, with patients worldwide dying every year from this avoidable complication 3

Detection and Prevention

• The use of video laryngoscopes can significantly reduce the occurrence of esophageal intubation by providing an improved view of the larynx 2
• Continuous waveform capnography is the most accurate method to determine tube placement after intubation and should be used to rapidly identify esophageal intubation 2, 4
• Clinical examinations such as auscultation of breath sounds, visualization of chest excursion, and observation of condensation in the tube are unreliable and should not be used to exclude esophageal intubation 2, 5
• The oesophageal detector device may be considered where other more reliable means are not available, but waveform capnography remains the reference standard for confirmation of tracheal intubation 5
• Portable handheld point-of-care ultrasound is an emerging technology for detection of potentially unrecognized esophageal intubations 6

Recommendations

• Videolaryngoscopy, capnography, and oxygen saturation monitoring should be used for all tracheal intubations to prevent unrecognized esophageal intubation 4
• A shared and vocalised report of videolaryngoscopy view and trained assistants working with the operator can help minimize error and improve team working 4
• If an esophageal intubation is suspected, the tube should be removed unless there is clear danger in doing so, and its position should be confirmed using repeat videolaryngoscopy plus one other method such as bronchoscopy, skilled ultrasound, or use of an oesophageal detector device 4