Accidental bronchial intubation. An analysis of AIMS incident reports from 1988 to 1994 inclusive

Area of Science:

• Anesthesiology
• Patient Safety
• Medical Incidents

Background:

• Accidental bronchial intubation is a recognized risk during anesthesia.
• Monitoring patient safety incidents is vital for improving clinical practice.

Purpose of the Study:

• To analyze the incidence, circumstances, and outcomes of accidental bronchial intubation.
• To identify preventable factors and propose strategies to reduce these events.

Main Methods:

• Retrospective analysis of 3947 incidents reported to the Australian Incident Monitoring Study.
• Categorization of incidents based on timing, setting, detection methods, and contributing factors.

Main Results:

• 154 (3.7%) incidents involved accidental bronchial intubation, predominantly during anesthesia maintenance in the operating theatre.
• Unexplained oxygen desaturation was the primary detection method (63.6%), with normal capnography in 88.5% of cases.
• Major morbidity occurred in 3 cases; 90% of incidents were preventable, with proposed tracheal tube markings potentially avoiding 61.1%.

Conclusions:

• Arterial oxygen desaturation during anesthesia necessitates consideration of bronchial intubation.
• Clinical detection of asymmetrical ventilation is challenging, often without capnographic changes.
• Implementing proposed tracheal tube markings could significantly reduce preventable bronchial intubation incidents.