Thread by @doctimcook

PREVENTING UNDETECTED OESOPHAGEAL INTUBATION. A thread @RCoANews @dasairway @ICS_updates @FICMNews @CollegeODP @SaferSurgeryUK @BACCNUK @MartinBromiley

It is rare
It is fatal
It is avoidable
Sadly it still happens

1/16

rcoa.ac.uk/news/rcoa-das-…

Glenda's was not a difficult airway case.

Please DO READ this judiciary.uk/publications/g…

2/16

Ten years ago in NAP4 there were 9 cases of undetected oesophageal intubation with harm reported.

No location was exempt.

3/16

Technology - capnography - identifies when intubation fails
It should be used for all tracheal intubations (& remain until after extubation) wherever/whenever they occur

A flat capnograph should be assumed to be due to oesophageal intubation until actively excluded

4/16

Capnography is not an added extra it is a mandatory part and parcel of tracheal intubation.

Standards say so - and have done for years.
…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

5/16

...everyone involved in airway management should be able to interpret a capnograph trace

No its not complex.
Keep it simple.
In Bath we use hats and caps: posh hats are good!

…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

6/16

Yes there are many other cases of a flat capnograph...but it's not anaphylaxis or bronchospasm until you've first excluded oesophageal intubation

The consequences are catastrophic

7/16

This is also the case during cardiac arrest

During cardiac arrest
-a flat capnograph must first be assumed to be due to oesophageal intubation....until this is excluded
-if the tube is in the trachea there will be an attenuated capnograph trace

8/16

Video on 'no trace = wrong place' is here.
Please watch it.
rcoa.ac.uk/safety-standar…

9/16

.....but its about more than capnography.
This 'traps' the error but can we prevent the error?

Human factors/ergonomics teaches us that 90% of the solution should be design (prevention) rather than barriers (error trapping)
@Fionafionakel @RCoANews

10/16

Some thoughts on error prevention & undetected oesophageal intubation

Videolaryngoscopy
Consistent monitoring

Hardware is important in performance (& IS part of human factors and ergonomics)

@Fionafionakel states 'good technical skills make space for good human factors'

11/16

...but training, including & respecting the team changes the culture.
It empowers staff in a crisis.
It's more about behaviour than kit.
'Change intubation from 'me to we'

When I talk about the 'shared airway' I mean everyone on the room can contribute

12/16

If coming into a crisis situation - what do you do?
How to apprise the situation & use fresh eyes?

I like SNAPPI
pubmed.ncbi.nlm.nih.gov/24561645/

13/16

In a crisis behaviour may/will deteriorate.
Even in good people!
Perseveration is common
How to intervene safely and professionally

Here I like PACE

14/16

We all need to act together to recognise that we can fail individually & are more likely to succeed as a team.

We need to embrace technology & optimise team behaviour

Lets get rid of undetected oesophageal intubation and avoidable patient harm & deaths.

15/16

Preventing undetected oesophageal intubation
Let's act.

16/16

17/16
As an addendum
I'm confident capnography use is ingrained in UK clinical practice. A success of #NAP4 & the airway leads network

The low rates of capnography use in countries beyond the UK is a major cause of concern & a safety issue
@RussottoVin @ESICM @ASALifeline

@MartinBromiley's tweet yesterday was very important here.


In his introduction to NAP4 Martin included this.
So let's be
-slow to judge others
-quick to learn ourselves

To trap undetected oesophageal intubation who is or is not up for this?

1/2

To trap undetected oesophageal intubation who is or is not up for a two person verbal check of capnography?

It would be great to see this re-tweeted so we can get a good number of votes to inform us of opinion.
Its a matter of professional importance
@dasairway @dastrainees @DAS_2021 @RCoANews @AAGBI @ICS_updates

Thanks