In what situation would a provider intentionally place an endotracheal tube (ETT) in the esophagus to divert vomit in a patient, such as an adult or pediatric patient with a history of gastrointestinal issues, pregnancy, or other conditions increasing the risk of vomiting, during rapid sequence intubation (RSI)?

Intentional Esophageal Intubation During Active Vomiting

Intentional placement of an endotracheal tube in the esophagus is a rescue technique reserved exclusively for the rare emergency situation of massive, ongoing vomiting that completely overwhelms suction capabilities and prevents visualization of the larynx during attempted intubation. 1

The Specific Clinical Scenario

This is an extremely uncommon maneuver used only when:

• Massive ongoing vomiting is present that cannot be controlled with standard suctioning 1
• The volume of vomitus completely overwhelms all available suction capabilities 1
• Visualization of the larynx is impossible due to continuous flow of gastric contents 1
• The patient requires emergent airway management (such as respiratory distress from aspiration) 1

The Technique

• Perform blind intubation of the esophagus with a standard endotracheal tube 1
• This creates a conduit that diverts ongoing vomitus away from the airway and out through the esophageal tube 1
• After brief suctioning of residual material, the larynx can then be quickly visualized 1
• The patient is then successfully intubated in the trachea with a second endotracheal tube 1

Critical Context: This is NOT Standard Practice

This technique is not mentioned in any major airway management guidelines 2, 3, 4, 5 and represents an improvised rescue maneuver documented in a single case report 1.

Standard RSI protocols for high-aspiration-risk patients focus on prevention rather than this rescue technique:

• Pre-induction nasogastric decompression with a large-bore tube to remove gastric contents before induction 3, 4
• Semi-Fowler positioning (head and torso elevated 20-30 degrees) to reduce aspiration risk 2, 3, 4, 5
• Rapid administration of induction agent and neuromuscular blocker to minimize time between loss of protective reflexes and securing the airway 4, 5
• Maximum three intubation attempts before moving to failed airway algorithm 2, 3, 4

When NOT to Use This Technique

This is not indicated for routine RSI in patients at risk of aspiration, even those with:

• High-grade small bowel obstruction 3
• Pregnancy 2, 5
• Recent food intake 6
• Gastroesophageal reflux 4

For these patients, use standard RSI with appropriate modifications as outlined above 3, 4, 5.

Important Caveat

The presence of massive gastric distention in an intubated patient can indicate a defective airway with abnormal communication between the endotracheal tube and gastrointestinal tract, which represents a potentially lethal complication requiring immediate recognition 7.