An Institution-Wide Rule-Based Protocol for Early Detection of Esophageal Intubation

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In an interesting study recently published in Anesthesia & Analgesia, Honardar et al1 stated that the most common factors contributing to delayed detection of esophageal intubation in 45 malpractice claims for esophageal intubation were not using, ignoring, or misinterpreting CO2 readings. I found this study interesting due to my previous attempts to quantify the sensitivity and specificity of end-tidal CO2 and other common clinical signs for early detection of esophageal intubation in the laboratory model.2 Since a human study to replicate my laboratory study would not be ethically acceptable, I thank the authors for providing much-needed detailed clinical information on 7 cases. I have summarized data on those cases in a Table to allow comparison of CO2 versus other signs for detection of esophageal intubation. Compared to all other signs, ETCO2 had the highest sensitivity and specificity, and these findings are comparable to my work in the laboratory model.1,2 Furthermore, the authors review the types of cognitive errors that may have contributed to delayed detection of esophageal intubation and suggest some workplace strategies that may help with this problem, but they also acknowledge that these strategies have not been tested in the real world, and their benefits are unproven. Based on my work and information summarized in the Table, it can be seen that the most common factor in esophageal intubation was absence of ETCO2, or abnormal quality of the capnogram, and that other signs were unreliable. Therefore, I would suggest that a standardized “rule-based” protocol to remove and replace the endotracheal tube, with independent verification by another physician in any circumstance in which the capnogram is abnormal or undetectable, would be easier to implement at an institutional level.
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