Abstract
This analysis primarily sought to determine the effectiveness of end-tidal capnography
for tube placement confirmation during emergency airway management. Secondary objectives
were validation of the rate of unanticipated esophageal placement during emergency
intubation and quantification of the portion of intubations performed in patients
with cardiac arrest where capnography is not recommended. The study was performed
in two phases. For the primary objective, a meta-analysis was performed on all experimental
capnography trials enrolling emergency populations. For the secondary objectives,
inadvertent esophageal intubation and cardiac arrest rates were calculated from a
large prospective multicenter observational study of emergency intubation cases. Data
analysis included calculation of descriptive statistics, sensitivity, specificity,
and confidence intervals (CI). Based on 2,192 intubations, a meta-analysis of previous
capnography trials resulted in an aggregate sensitivity of 93% (95% CI 92–94%) and
an aggregate specificity of 97% (CI 93–99%) for emergency tube placement confirmation.
Thus, for emergency capnography use, the false-negative failure rate (tube in trachea
but capnography reports esophagus) was 7% and the false-positive rate (tube in esophagus
but capnography reports trachea) was 3%. This translates to potential harm for one
patient in every 10 treated with capnographic confirmation alone (number needed to
harm: 14 for false-negative, 33 for false-positive, and 10 for both). A further literature
review demonstrated no sole method of tube placement confirmation is completely foolproof.
Of 4,602 consecutive intubations reported to the National Emergency Airway Registry,
4% of emergency intubation attempts resulted in accidental esophageal intubation,
and 10% occurred in nontraumatic cardiac arrest patients. During tracheal intubation
of critically ill patients, it is concluded that the rate of accidental esophageal
tube placement warrants continued improvement in emergency airway techniques. Misidentification
of esophageal placement in the emergency setting may occur with capnography. Multiple
methods of tube placement confirmation are superior to any single method because no
single method has perfect accuracy.
Keywords
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References
- Rapid-sequence intubation comes of age.Ann Emerg Med. 1996; 28: 79-81
American College of Emergency Physicians. Rapid-sequence intubation [position statement 400177], 1996.
- Advanced trauma life support for doctors, 6th edn. ACS, Chicago1997
- Complications of emergency intubation with and without paralysis.Am J Emerg Med. 1999; 17: 141-143
Salem MR, Wafai Y. Practical confirmation of endotracheal intubation in the trauma patient. Anesthesiology News 1997;Jan:4–32.
Gawande A. When doctors make mistakes. New Yorker 1999;Feb 1:40–55.
- Accidental intubation of the oesophagus.Anaesth Intensive Care. 1980; 8: 183-186
- Death and other complications of emergency airway management in critically ill adults.Anesthesiology. 1995; 82: 367-376
- Aspirated air capnography with esophageal detector device to confirm tracheal intubation in rapid sequence induction.Middle East J Anesthesiol. 1998; 14: 381-386
- Improving the quality of reports of meta-analyses of randomised controlled trials.Lancet. 1999; 354: 1896-1900
- Safety evaluation and confidence intervals when number of observed events is small or zero.Ann Emerg Med. 1997; 30: 301-306
- The self-inflating bulb to detect esophageal intubation during emergency airway management.Anesthesiology. 1998; 88: 898-902
- Confirmation of ETT placement after emergency intubation.Anesthesiology. 1996; 34 ([abstract]): A232
- A disposable end-tidal CO2 detector to verify endotracheal intubation.Ann Emerg Med. 1991; 20: 271-275
- Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for verifying endotracheal tube placement in the prehospital setting.Prehospital Disaster Med. 1997; 12: 57-63
- Clinical utility of a colorimetric end-tidal CO2 detector in cardiopulmonary resuscitation and emergency intubation.J Clin Monit. 1991; 7: 289-293
- Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest.Acad Emerg Med. 1995; 2: 499-502
- Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection.Ann Emerg Med. 1991; 20: 267-270
- Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device.Ann Emerg Med. 1992; 21: 518-523
- Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children.Ann Emerg Med. 1992; 21: 142-145
- Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation.Ann Emerg Med. 1996; 27: 595-599
- Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation.Pediatrics. 1995; 95: 395-399
- Portable devices used to detect endotracheal intubation during emergency situations.Crit Care Med. 1998; 26: 957-964
- Auscultation cannot distinguish esophageal from tracheal passage of tube.J Clin Monit. 1991; 7: 232-236
- Esophageal intubation.Anesth Analg. 1986; 65: 886-891
- Signs of endotracheal intubation.Anesthesia. 1980; 35: 984-986
- Assessing the position of the tracheal tube. The reliability of different methods.Anaesthesia. 1989; 44: 984-985
- Alteration of endotracheal tube position. Flexion and extension of the neck.Crit Care Med. 1976; 4: 7-12
- Respiratory recording from the oesophagus.Br Med J. 1974; 4: 225
- Endotracheal tube misplacement.Anaesth Intensive Care. 1982; 10: 274-276
- Condensation on tracheal tubes is commonly seen with oesophageal intubation.Br J Anaesth. 1995; 75: 115-116
- Efficacy of endotracheal tube cuff palpation and humidity in distinguishing endotracheal from esophageal intubation.Anesthesiology. 1988; 69 ([abstract]): A265
- The self-inflating bulb for confirmation of tracheal intubation.Anesthesiology. 1994; 81 ([abstract]): A1303
- Out-of-hospital experience with the syringe esophageal detector device.Acad Emerg Med. 1997; 4: 563-568
- The self-inflating bulb for confirmation of intubation.Anesthesiology. 1994; 81 ([abstract]): A1303
- Efficacy of the self-inflating bulb in confirming tracheal intubation in the morbidly obese.Anesthesiology. 1996; 85: 246-253
- Esophageal detector device.Ann Emerg Med. 1996; 28: 582
- Radiographic detection of esophageal malpositioning of endotracheal tubes.Am J Roentgenol. 1990; 154: 23-26
- Comparison of end-tidal carbon dioxide, oxygen saturation and clinical signs for the detection of oesophageal intubation.Can J Anaesth. 1989; 36: 560-564
- Adverse respiratory events in anesthesia.Anesthesiology. 1990; 72: 828-833
Welch R. CO2 monitoring. The quest to verify ETT placement. J Emerg Med Serv 1996:95–100.
- Tracheal intubation is not invariably confirmed by capnography.Anesthesiology. 1990; 73: 1285-1287
- Unusual cause of an absent capnogram.Anesthesiology. 1989; 71: 992-993
- Esophageal intubation.Anesth Analg. 1987; 66: 481-483
- False-positive end-tidal CO2.Ann Emerg Med. 1996; 28: 458-459
- Capnography for detection of accidental oesophageal intubation.Acta Anaesthesiol Scand. 1983; 27: 199-202
- Detection of oesophageal intubation.Anaesthesia. 1989; 44: 81-83
- Detection of oesophageal intubation.Anaesthesia. 1992; 47: 70-71
- Reliability of capnography in identifying esophageal intubation with carbonated beverage or antacid in the stomach.Anesth Analg. 1991; 73: 333-337
- End-tidal CO2 detection.Ann Emerg Med. 1989; 18: 1375-1378
- Planning the measurements.in: Hulley S.B Cummings S.R Designing clinical research. Williams & Wilkins, Baltimore1988: 40
American Society of Anesthesiologists. Standards for basic intraoperative monitoring. ASA Newsletter 1996.
- Confirmation of airway placement.Prehosp Emerg Care. 1999; 3: 273-278
Article info
Publication history
Accepted:
October 16,
2000
Received in revised form:
October 2,
2000
Received:
April 10,
2000
Identification
Copyright
© 2001 Elsevier Science Inc. Published by Elsevier Inc. All rights reserved.
