Unrecognized misplacement of endotracheal tubes by ground prehospital providers

Endotracheal intubation by emergency medical services (EMS) is well established. Esophageal misplacement is a catastrophic complication that has until recently been studied by using methods that have called into question the accuracy of the reported data. The purpose of our study was to determine the incidence of unrecognized endotracheal tube misplacement, reasons for deferred intubations in the field, and to report outcomes in those patients with unrecognized misplacement.

This was a prospective observational study with a consecutive sample. All arriving with an endotracheal tube or in whom endotracheal intubation was performed within 10 minutes of arrival were included, and a physician immediately determined placement. Hospital records were reviewed to determine outcome of those patients in whom the tube was misplaced. Unrecognized esophageal misplacement triggered communication to the medical director of the transporting agency.

During the enrollment period, 192 patients were evaluated. Overall, 132 of 192 (69%) were intubated in the prehospital environment, and 60 were intubated within 10 minutes of arrival in the emergency department. Among prehospital intubation attempts, 12 of 132 (9%; 95 CI 5.3-15.2), 11 esophageal, and 1 hypopharyngeal were misplaced. Right mainstem intubation occurred in an additional 20 of 132 (15%; 95 CI 10.0-22.3). Among patients arriving with unrecognized esophageal misplacement of the endotracheal tube, one patient survived to hospital discharge.

The rate of esophageal misplacement of endotracheal tubes in the prehospital environment in our urban setting and the poor clinical course of patients with unrecognized misplacement is consistent with previous reports, suggesting that the benefit of prehospital airway management does not clearly supercede the potential risks.