SALG, on behalf of the RCoA responded jointly with the Faculty of Intensive Care Medicine, to a report from a coroner of the death of a patient due to unrecognised oesophageal intubation.  A short case summary, from the information that appears in the coroners’ report appears below:

[The deceased] …had taken an overdose of medication which caused their collapse. They were taken to hospital and required intubation. During the procedure the tube was accidentally positioned in the oesophagus, this accidental misplacement should have been identified by the lack of a sustained capnograph at that time. [and possibly due to the volume of vomit coming from the tube and

Those in attendance during intubation remembered seeing ‘a few’ end tidal carbon dioxide traces, and other indicators (chest wall movement, breath sounds in the chest, fogging in the tube) which they felt at the time supported the view that the tube was in the right place. It is possible that the tube was initially in the trachea, but as it was not tied in, it became displaced. This would account for the fact that those in attendance were sure that they had seen 3 breaths on the capnograph trace but this was not checked again when events suggested the tube might have become displaced.

Once accidental osophageal intubation was recognised [the patient] was correctly intubated.

The incorrect placement caused [the patient] to suffer a cardiac arrest, which led to hypoxic encephalopathy and … death“.

It remains a great concern that such incidents continue to take place, despite the work previously carried out by the specialty to try to ensure that oesophageal intubations are swiftly recognised and corrected, details of which are available on the RCoA website.¹

A sustained capnography trace is the only reliable test, to confirm that a tracheal tube is in the right place and should override the results of all other checks. This is made clear in the Association of Anaesthetists’ “Standards of monitoring during anaesthesia and recovery”.²

The Project for Universal Management of Airways (PUMA) consensus guidelines,³  emphasise “sustained exhaled carbon dioxide” as the test to exclude oesophageal intubation.  This reflects the fact that in some cases of oesophageal intubation the capnograph trace has not been flat, but instead was attenuated and abnormal. Our organisations are supportive of the PUMA guidelines and plan to disseminate the key messages to our members through our safety communications and events.

1. Royal College of Anaesthetists. Patient Safety: Unrecognised Oesophageal Intubation. Available: https://www.rcoa.ac.uk/safety-standards-quality/patient-safety/prevention-future-deaths

2. Association of Anaesthetists, Recommendations for standards of monitoring during anaesthesia and recovery, 2021, https://anaesthetists.org/Home/Resources-publications/Guidelines/Recommendations-for-standards-of-monitoring-during-anaesthesia-and-recovery-2021

3. Chrimes, N. et al, (2022), Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia, 77: 1395-1415. https://doi.org/10.1111/anae.15817