Over the years I have come to understand that there are a few phrases that should make you STOP and THINK before you do anything else. I picked this up while flying around in different areas of the country where I saw that some areas have great and aggressive thinkers/doers, while others seem to be predisposed to questionable decision making.
Keeping a calm/cool head once you arrive to these situations is key. Support the team that was there before you It is key so that you can focus on some of those subtle clues or have the wherewithal to hit the pause button when you hear/see certain things.
Here is one phrase that I learned to make a hard stop and reevaluate things whenever I heard it:
“She was a really tough intubation…”
(Cue record scratching noise)…
After hearing that statement, your whole life (and your partner’s) is dedicated to confirming that the ET tube is in place… or not. Not by looking at chest X-ray. Not with chest rise and fall. Not with misting in the tube. All of these and many more “confirmation methods” have been debunked and are no longer recommended as primary OR secondary means of tube confirmation. They can all still be present with an ET tube in the wrong place.1
While it should be a rare occurrence, an ET tube does occasionally present to a team in the esophagus. A number of things can contribute to this from inexperience of the operator to glottic impersonation1-2 and as long as it is recognized early as being malpositioned then the harm is reduced. When a tube is left in the esophagus and the operator is troubleshooting everything but the tube itself in an attempt to correct oxygenation issues (or why the tube keeps filling up with shmutz) is when things become dangerous for the patient. The patient can become irreparably hypoxic and suffer anoxic brain injury if we miss this.
Some of the things I listen for when getting a report for a patient who was intubated prior to arrival:
1.) Multiple attempts
2.) Bloody airway
3.) Vomited prior to intubation
4.) Facial trauma
5.) “Routine”
6.) “A lot of swelling…”
7.) Constant ventilator alarming with pressure issues.
Each of these peak my interest in ensuring that the tube is not in the esophagus. As does a team that is frazzled when I get there. While a great waveform on the capnometry line on the monitor is reassuring, any variation will prompt me to look in the airway and confirm beyond any doubt that the tube is in the correct place.
Note: Glottic impersonation is what happens when the instrumentation of the airway blanches the tissues around the esophagus making the edges appear white. Our brains take a mental shortcut and see a dark hole with white edges and determine that this is the target for the ET tube.2
Beyond a Shadow of a Doubt
Qualitative waveform capnography is the “gold standard,” but nothing will beat going back in to see that the tube is where it should be with VL. Sometimes it is best to leave no doubt. The mindset is a little different in these situations. When I hear that the folks before me had a difficult time placing the tube, perhaps even omitting one or two attempts from their story, I am not looking to ensure that tube is in the trachea. I want to know beyond a shadow of a doubt that it is NOT in the esophagus.1 I am looking for a consistent 4 phase waveform, and if I do not have that, I am going to look at the tube and airway myself.
The PUMA group, or Project for Universal Management of Airways, has published a plethora of research on the prevention of unrecognized esophageal intubations. They have demonstrated that there are only a couple of ways to definitively rule out an esophageal intubation if there is not a sustained 4 phase waveform on capnography:
When in doubt, pull it out. The risk of another intubation attempt pales in comparison to an unrecognized esophageal intubation. This should be the default response.1
References:
) Chrimes N, Higgs A, Hagberg CA, Baker PA, Cooper RM, Greif R, Kovacs G, Law JA, Marshall SD, Myatra SN, O’Sullivan EP, Rosenblatt WH, Ross CH, Sakles JC, Sorbello M, Cook TM. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia. 2022 Dec;77(12):1395-1415. doi: 10.1111/anae.15817. Epub 2022 Aug 17. PMID: 35977431; PMCID: PMC9804892.
Kovacs, G., Duggan, L.V. & Brindley, P.G. Glottic impersonation. Can J Anesth/J Can Anesth 64, 320 (2017). https://doi.org/10.1007/s12630-016-0804-x
