Preventing unrecognised oesophageal intubation

Major harm from unrecognised oesophageal intubation continues, despite the 2018 Royal College of Anaesthetists' 'no trace, wrong place' campaign. It is likely that publicly reported cases represent a fraction of real occurrences. This article summarises a 2022 consensus guideline on the prevention of unrecognised oesophageal intubation from the Project for Universal Management of Airway and international airway societies. The guideline is written for all airway operators and assistants, in any clinical setting, and readers are advised to deepen their understanding by studying the original guideline. The recommendations include how to avoid and recognise oesophageal intubation as well as a set of logical actions to take when it is a plausible possibility, even if it is not suspected. The guideline emphasises the importance of videolaryngoscopy, capnography and oxygen saturation monitoring for all tracheal intubations, wherever performed. It introduces the concept of sustained exhaled carbon dioxide, which is central to identifying oesophageal intubation, and acting to prevent progression to unrecognised oesophageal intubation. In the absence of sustained exhaled carbon dioxide, the default action is to remove the tube. This will mean some tracheal placed tubes are removed but based on a risk-benefit analysis, this is desirable. The tube should only be left in place if there is clear danger in removing it and in this event, its position should be confirmed, using repeat videolaryngoscopy plus one other of bronchoscopy, skilled ultrasound or use of an oesophageal detector device. The importance of human factors is underlined; for instance, the value of a shared and vocalised report of videolaryngoscopy view and trained assistants working with the operator to confirm whether the criteria for sustained exhaled carbon dioxide are met, to minimise error and improve team working.