Episode #179 A Preventable Airway Disaster

December 5, 2023

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Our featured article today is “A Preventable Airway Management Disaster” by Felipe Urdaneta.

In 2022, Chrimes and colleagues published an international consensus guideline dedicated to preventing unrecognized esophageal intubation. This updated guideline is brought to us by the Project for Universal Management of Airways, and 7 international airway management societies have endorsed these guidelines that are focused on preventing unrecognized or undetected esophageal intubation. Here is the citation:

  • Chrimes N, Higgs A, Hagberg CA, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia. 2022;77:1395–1415. PMID: 35977431

Have you ever wanted to contribute to the APSF newsletter? Maybe you are thinking about writing a Letter to the Editor. This type of article can comment on a past article or a current perioperative patient safety issue, like unrecognized esophageal intubation. The letter to the editor should be no more than 500 words with no more than 5 references. The next deadline is March 10th, and we hope to hear from you in the new year!

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© 2023, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We have a special show today. This is a Letter to the Editor show with exclusive content from the author. So, grab your copy of the October 2023 APSF Newsletter and get ready for an all-new show this week.

But before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.

Our featured article today is “A Preventable Airway Management Disaster” by Felipe Urdaneta. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. From here, scroll down until you get to our featured article today. I will include a link in the show notes as well.

Before we get into the article, we are going to hear from the author. Let’s take a listen.

[Urdaneta] “Well, hello. Uh, thank you for having me here. My name is Felipe Urdaneta. I’m a staff anesthesiologist at the Gainesville VA at the University of Florida, and I’m also a professor of anesthesiology at the University of Florida as well.

[Bechtel] To kick off the show today, I asked Urdaneta what got him interested in this important anesthesia patient safety topic. This is what he had to say.

[Urdaneta] “I would like to actually state why I got interested in this subject. So, as I was in training, um, I grew up with the notion that the esophageal intubation had disappeared. from our radar. But then in 2021, I got a hold and I was a reviewer for the article of the recent PUMA guidelines on esophageal intubation.

And in it, they started bringing again, Anecdotal reports of this subject appearing once again, and my concern and the concern that we all have is A, number one, it disappeared like we actually erroneously thought, and number two, because of the devastating consequences of having, uh, esophageal intubation and not recognizing it promptly, which ultimately is going to lead to Basically, uh, hypoxia, brain injury, and ultimately having a patient that is not doing well.

So that’s basically the source of my interest on the subject.

Why do I feel so passionate about the subject?

Well, I think number one is one of my main interests happen to be human factors in airway management. And specifically, why do we keep making not only errors, but the same errors over and over again. And one of them happens to be, uh, the issue of a septal glial intubation. I’m interested in the airway management as a system looking at basically, um, our task, our procedures, our work environment, our interaction with resources and looking at it not just in a form of technologies, but also as the workplace and processes at the individual level, at the group level.

And as the institutional or organizational level. That’s my, my main interest happens to be. I’m interested basically in looking at the mental demands, the physical demands, the temporal demands, and basically things that actually impact our performance when we’re dealing with this complicated issue of airway management.”

[Bechtel] Thank you so much to Urdaneta for bringing attention to the very real and present threat of esophageal intubation. Now, it’s time to get into the article which opens with a review of the evolution of airway management over the past 40 years with improved patient safety despite increased high-risk patients including extremes of size and weight, trauma, and obstructive sleep apnea. Safety during airway management has increased with the following advances:

  • Revised and updated airway management guidelines
  • Newer supraglottic airways
  • Indirect video laryngoscopes
  • Advances in invasive airway emergency methods
  • Advanced methods of peri-intubation oxygenation methods including non-invasive positive pressure ventilation and high-flow nasal oxygenation.

The author cautions us that even with these advances and improve patient safety during intubation procedures, this is not the time to let down our guards. Airway management procedures may be required for patients with different medical problems and by healthcare professionals with different training backgrounds and experience. We are still seeing adverse events and we must remain vigilant.

In 2022, Chrimes and colleagues published an international consensus guideline dedicated to preventing unrecognized esophageal intubation. I will include the citation in the show notes as well. This updated guideline is brought to us by the Project for Universal Management of Airways and international airway societies, actually 7 airway management societies from around the world have endorsed these guidelines that are focused on preventing unrecognized or undetected esophageal intubation. You might be thinking, “Is there a need for such guidelines in the 21st century?” Many, if not all, anesthesia professionals have performed laryngoscopy and intubation and had the endotracheal tube accidently end up in the esophagus. When this happens, immediate recognition is important to keep patients safe with removal of the endotracheal tube from the esophagus followed by correct placement in the trachea. However, patients are at risk for severe, irreversible hypoxic brain damage or death if there is delayed recognition or failure to recognize accidental esophageal intubation.

Let’s take a short excursion to the recently published guidelines and review the key recommendations now. I am going to read them now and the citation will be in the show notes.

  1. Monitoring for exhaled carbon dioxide and pulse oximetry should be available and used during airway management procedures.
  2. Routine use of video laryngoscopy is recommended if possible.
  3. During laryngoscopy, the airway operator should verbalize the view obtained.
  4. The airway operator and/or assistant should declare if there is sustained exhaled carbon dioxide and adequate oxygen saturation.
  5. If there is no sustained exhaled carbon dioxide, then esophageal intubation must be excluded.
  6. If there is no sustained exhaled carbon dioxide, the next step should be removal of the endotracheal tube and attempted mask ventilation or ventilation with a supraglottic airway.
  7. If there is no sustained exhaled carbon dioxide and the endotracheal tube is not removed immediately, you must actively exclude esophageal intubation with either repeat laryngoscopy, flexible bronchoscopy, ultrasound, or the use of an esophageal detector device.
  8. Clinical examination findings cannot exclude esophageal intubation.
  9. Removal of the endotracheal tube should occur in the following situations:
    • Cannot exclude esophageal placement.
    • No sustained exhaled carbon dioxide
    • Decreased oxygen saturation with failure to detect sustained exhaled carbon dioxide.
  10. Optimization of monitor displays is important with standardization and distinctive variables.
  11. Education with interprofessional education programs is important to implement the technical and team aspects of these new guidelines.

Are you following these guidelines at your institution? We hope so! And now it’s time to get back into the APSF Article.

What is the rate of unrecognized esophageal intubation? The exact rate is unknown, but the incidence may be as high as 4-26% of all intubations in high-risk groups such as trauma, low-flow states, and neonates. It is likely that the incidence is higher for airway management procedures performed outside of the operating room and when performed by non-anesthesia professionals. Keep in mind that anesthesia professionals may also be involved in an unrecognized esophageal intubation. Let’s take a look at the ASA Closed Claims Analysis for more information. In the 1980s, unrecognized esophageal intubation was responsible for 6% of all closed anesthesia malpractice claims. One decade later, the ASA required monitoring for adequate ventilation with detection of exhaled carbon dioxide unless invalidated by the nature of the patient, procedure, or equipment. Following this, unrecognized esophageal intubation events decreased significantly, possibly becoming a never event. In 2019, the ASA closed claims analysis revision reported no cases.

We need to dive a little further into the literature. Let’s check out the 2011 National Audit Project IV database. In this database, there were 9 cases of unrecognized esophageal intubation, and this was the second most common adverse event that resulted in death or disability. After this publication, the Difficult Airway Society and the Royal College of Anesthetists in Great Britain advocated for required capnography whenever airway procedures occurred. This important step, detection of exhaled CO2, was still not able to eliminate unrecognized esophageal intubation events though. It is also likely the case that these events continue to be underreported.

The author provides some insightful commentary on the new guidelines and the risk for unrecognized esophageal intubation. Strict protocols and teamwork care help to eliminate this event. In addition, the use of video laryngoscopy is well supported in the literature, but it may not be possible due to the perceived cost and resource limitations. It is vital to ensure correct tracheal tube placement with monitoring for exhaled CO2 and this monitoring should also be used continuously for patients requiring mechanical ventilation. Endotracheal tubes may become dislodged and migrate into the esophagus, so we need to remain vigilant especially for pediatric patients and during patient head and body movement or during resuscitation maneuvers.

There are reports of patients who may continue to breathe even with a misplaced tube, but following administration of neuromuscular blocking agents, there will be rapid deterioration and desaturation. Esophageal intubation must be high on the differential if it is impossible to ventilate a patient on a mechanical ventilator.

Anesthesia professionals at every stage in their careers and at all skill levels must remain vigilant for an esophageal intubation. We may not be able to prevent this from occurring, but the goals are to be able to quickly and accurately detect tracheal tube placement. The new guidelines can help us to do this. Urdaneta leaves us with a call to action that “no patient should be harmed by unrecognized esophageal intubation, and we should all abide by the fundamentals to reduce this unwanted event.”

Before we wrap up for today, we are going to hear from Urdaneta again. I also asked him what he hopes to see going forward. Let’s take a listen to what he had to say.

[Urdaneta] “What I see in the future about this is that we again bring it to the forefront and we can start actually having Uh, looking at guidelines and what I’m interested in is the fact that these guidelines point out that we now have a method and a systems to actually deal with this because first of all by using first choice or some of them call it, some people call it universal use of video laryngoscopy, we can decrease the incidences of a, of a reintubation.

But number two, by making the capnography as universal as well and making it Uh, looking at it immediately after extubation, we can detect all instances of, uh, esophageal intubation, or basically, placement of the tube in the right respiratory tract. And so, by making it universal is actually very important.

And number three, by bringing it to our, the tip of our tongue so that, uh, not only individually, but as a team, we can actually be aware. that that might happen. It still happens. And if we don’t detect it in a timely fashion, it’s going to lead to irreversible consequences.

I think this guidelines by making it clear that, first of all, we need to have it as part of our day to day activities, and we need to have it, uh, we don’t need to basically rule out, um, even though there are other issues as to why you may not have a positive waveform when we actually place a tube, um, we always have to think about the fact that esophgeal intubation needs to be kind of first and foremost that we need to discard.

I take actually the approach that, basically, the null hypothesis. That tube, Every time I place one, it’s going to end up in the wrong place until proven otherwise. And if you actually have that active phenomenon, that aggressive type of approach, then the chances are you’re always going to keep it in the top of your head and top of your mind because that’s what actually is needed about.”

[Bechtel] Thank you so much to Urdaneta for contributing to the show today and highlighting this important threat to anesthesia patient safety.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Have you ever wanted to contribute to the APSF newsletter? Maybe you are thinking about writing a Letter to the Editor. This type of article can comment on a past article or a current perioperative patient safety issue, like unrecognized esophageal intubation. The letter to the editor should be no more than 500 words with no more than 5 references. The next deadline is March 10th, and we hope to hear from you in the new year! Check out the APSF Guide for Authors under the Newsletter heading at apsf.org and I will include a link in the show notes as well.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation