In case of oesophageal intubation

Just published Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Thanks to a prestigious panel of international authors. Great job and definitely solid indication about how to prevent and recognise accidental oesophageal intubation.

Just some of the key recommendations

• Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
• Routine use of a videolaryngoscope is recommended whenever feasible.
• Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded.
• Tube removal should be undertaken if any of the following are true:
  • Oesophageal placement cannot be excluded
  • Sustained exhaled carbon dioxide cannot be restored
  • Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide

Refer to the full text guidelines for more.
Here is the link to Safe Airway Society livestream event.
Must read, must follow. Free open access.

Let’s go outside

The following are personal considerations on peculiar aspects about management of accidental oesophageal intubation in prehospital environment and come from my personal clinical experience.

Beware they are just personal considerations and practical tricks and tips and are not intended to substitute the above guidelines. 

They are intended to suggest an alternative mental and technical approach when dealing with oesophageal intubation on uncontrolled patients in difficult environment.

Some general considerations

1. Prehospital uncontrolled patients are not on empty stomach so are at high risk of regurgitation/inhalation
2. Even few ventilation efforts in case of oesophageal intubation pone the patient at high risk of regurgitation/inhalation 
3. Suctioning in prehospital setting is not always ready avalliate (mind your environment) or maximally performant (mind your equipment) 
4. First attempt in prehospital setting must be always the best one. Think before trying a second attempt in case of failure. Implement your plan or change plan.
5. Apply the Indication, Suitability, Feasibility approach while supporting oxygenation, ventilation and protection.

DO NOT REMOVE THE OT TUBE STRAIGHT FORWARD IN CASE OF ACCIDENTAL OESOPHAGEAL INTUBATION IN PREHOSPITAL ENVIRONMENT.

The way I like it. The way I do it.

1. Live the “oesophageal” OT tube in (overcuffed) and if it’s possible apply a continuous suctioning to exclude the oesophagus and protect the airways 
2. Place a SGA to restore oxygenation and ventilation (trough BMV or NIV)
3. After restoring oxygenation (SaO2 >94%) and ventilation (EtCO2 40 mmHg) if suitable and feasible (see below) proceed to a second attempt of tracheal intubation (must be videolaryngoscope+bougie)
4. If the second attempt succeeds remove the “oesophageal” OT
5. If the second attempt is not suitable or feasible transport to nearest hospital (patient is well oxygenated and ventilated via SGA and protected via oesophageal exclusion) for further stabilisation (you can replace the oesophageal OT tube with a large bore oro-gastric tube or insert the orogastric tube trough the SGA dedicated channel)
6. If you can’t restore oxygenation and ventilation via SGA or you can’t place a SGA remove the oesophageal OT tube and try to oxygenate and ventilate (remember patient is not protected) via BVM and NC (double oxygenation) 
7. If even BVM fails declare CICO 

Suitability 

• Do I have a plan to implement regarding the  first attempt
• Can I improve my environment (Setting) moving the patient to a more comfortable place/position 
• Is the time to nearest hospital short/long 

Feasibility 

• Am I in the right mental mood after 1st attempt (me) to try a better second one
• Is my team ready for a second attempt (team) 
• Do I have the right equipment to implement my second attempt (Equipment)

The visual algorithm

The Video