Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies (17 August 2022)

Summary

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.

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.

Content

Key recommendations

• Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
• Routine use of a videolaryngoscope is recommended whenever feasible.
• At each attempt at laryngoscopy, the airway operator is encouraged to verbalise the view obtained.
• The airway operator and assistant should each verbalise whether ‘sustained exhaled carbon dioxide’ and adequate oxygen saturation are present.
• Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded.
• The default response to the failure to satisfy the criteria for sustained exhaled carbon dioxide should be to remove the tube and attempt ventilation using a facemask or supraglottic airway.
• If immediate tube removal is not undertaken, actively exclude oesophageal intubation: repeat laryngoscopy, flexible bronchoscopy, ultrasound and use of an oesophageal detector device are valid techniques.
• Clinical examination should not be used to exclude oesophageal intubation.

Tube removal should be undertaken if any of the following are true:

• Oesophageal placement cannot be excluded
• Sustained exhaled carbon dioxide cannot be restored
• Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide.

Actions should be taken to standardise and improve the distinctiveness of variables on monitor displays.

Interprofessional education programmes addressing the technical and team aspects of task performance should be undertaken to implement these guidelines.