® CLINICAL BRIEF Unrecognized Esophageal Placement of Endotracheal Tubes JOHN ADRIANI, MD, New Orleans, La IT IS ESTIMATED that more than 1,000 unrecog- nized esophageal placements of endotracheal tubes, followed by catastrophic sequelae, occur annually throughout the nation during attempted intubation.' Supportive statistical data to substan- tiate this estimate are not available,? and it appears to be exaggerated, Nonetheless, that such mishaps do occur cannot be denied, and that they occur with greater frequency than they should likewise cannot be denied. Even. one occurrence is one too many. Although most occurrences are associated with anesthesia, some follow attempis to intubate and ventilate unanesthetized apneic patients. A review of medical records from cases in which pro- ceedings for malpractice have been instituted for alleged misplacement of endotracheal tubes dur- ing anesthesia suggests that the following scenario is typical and appears to recur with unrelenting frequency. CASE REPORT ‘An obese woman (weight 250 ib, height 5 ft 4 inches) with an unremarkable medical history and no history of previous operations was admitted to a hospital for an abdominal hysterectomy for fibromyoma ofthe uterus. At 6 AM she was premedicated with 75 mg of meperidine, 0.4 mg of atropine, and 50 mg of hydroxyzine intramuscularly, and was taken to the operating room at 7 am. An infusion of lactated Ringer's solution and dextrose was stated using an 18 gauge indwelling needle. An ECG monitor and precordial stethoscope were attached. Anesthesia was induced with 250 mg of intra- vvenaus thiopental at 7:30. This was followed immediately by 3 mg of d-tuboeurarine to avert fasciulations. Suecnylehotine (80 mg) was then given to facilitate intubation. Despite dif ficuty in viewing the voeal cords, on the third attempt the patient was intubated suecessfully with a No. 8 endotracheal Catheter with alow pressure cuff using a Miler blade. Auscults- tion revealed audible breath sounds bilaterally. Anesthesia was maintained with pancuronium (8 mg), nitrous oxide (4 L), oxygen (2 L), and enflurane (Ethrane) (1.5%). Blood From fe Department of Anexteilogy and Pharmacsogy, Louisiana Sate piety dhe paren ‘aoBubeilogy: Caely Howpl, New leans, ‘Reprint requests to John Advani, MD, Deparment of Ancsthesilogy, Ccharkty Hospital, New Orleans, LA 70140. . pressure at the onset of anesthesia was 120/80 mm Hg, and the pulse rate was 80/min. After intubation, the blood pressure rose t0 130/86, and the pulse rate increased to 100. Five ‘minutes later, the blood pressure was 140/80 and the pulse rate decreased to 80; 50 seconds later, the pulse rate was 70. Within the next three minutes, the blood pressure decrease +0 60/40; the pulse rate deereased to 60, and the ECG monitor showed a sinus bradycardia with normal complexes. When the surgical incision was made seven minutes after induction of anesthesia the surgeon commented that the blood was dark ‘The patient became inereasingly cyanotic. Administration of the nitrous oxide and enflurane was discontinued and ven- tilation was done with 100% oxygen via a bag and mask, but the cyanosis persisted. Atropine, 0.4 mg, was given intra- venously but without effect. One minute later, an additional 0.4 mg of atropine was given, also without effect. Ephedrine (25 mg) was then given without effect. Compression of the bag became progressively more difficult. One minute later, neither the pulse nor the blood pressure were obtainable and the ECG tracing was isoelectric. Cardiac arrest was diagnosed and a code was called. An anesthesiologist who had been sum- ‘moned arrived almost simultaneously withthe code team, He ‘withdrew the endotracheal tube, inserted an oral aieway, and ventilated the patient with a bag and mask for several minutes before reintubation. The cardiac arrest team instituted cardiac compression. Blood drawn for gas analysis when the code team arrived showed severe acidosis, with a PO of 40 torr, pH of 7.10, PaCO: of 5 torr, and HCOs of 12 mEa/L. Epinephrine, sodium bicarbonate, and calcium gluconate were given. A nasogastric tube was inserted, yielding approximately 350 ml of gas of undetermined composition. ‘The pulse became palpable and gradually rose to 80/min. The blood pressure was palpated at 80 systolic. Several minutes later it was auscultated at 100/60 mm He, and two minutes lacer it was 120/80. Ten minutes afer resuscitation was begun, the blood pressure was 150/90, and the pulse rate had increased to 130/min, ‘The eyanosis gradually cleared. One hour later, spontaneous breathing had resumed but the exchange was in: adequate, and because respiration had to be assisted the pa tient was placed on a ventilator. Consciousness had not returned. Blood gases, cardiac rhythm, and blood pressure, etermined one half hour later and at one-hour intervals after- ‘ward for the next four hours, returned to normal levels. Two hhours later, seizures developed and were controlled with diazepam, ‘The patient remained comatose and died five days later. The diagnosis entered on the death certificate was “brain death, cause unknown.” Hypoxie brain damage had been Siagnosed by a consulting neurologist and confirmed by elee- twoencephalography and later at autopsy. No evidence of any type of emboli, aspiration, or myocardial or pulmonary disease Adrian © MISPLACEMENT OF ENDOTRACHEAL TUBES 1591was uncovered, Patchy areas of atelectasis were present in the Tung, and several healing contusions were preset in the upper part of the esophagus. COMMENT In this case the telltale signs that support the conclusion that the tube was in the esophagus, in- stead of the trachea, are successful resuscitation and the prompt return of blood gases to normal levels afier reintubation. The hypoxic state developed gradually over a period of ten minutes or more, Its difficult to envision anyone familiar with airway control sitting blithely by and allow- ing such a situation to deteriorate to the point of asphyxia without promptly instituting corrective measures. Everyone who has performed en- dotracheal intubation with any degree of frequency has, at one time or another, inadvertently placed an endotracheal tube in the esophagus instead of the trachea. Nothing is wrong with that if the misplacement is promptly recognized and cor- rected. Intubations are not uniformly simple, as everyone who has attempted them knows. In- variably the misplacement is obvious and the er- ror can be corrected. In most cases, the thorax can be seen to rise with inflation induced by com- pression of the ventilating bag and fall with defla- tion. In obese subjects and those with barrel chests and fixed chest walls, these signs are not im- mediately apparent. ROLE OF MUSCLE RELAXANTS. Before the neuromuscular blocking agents became widely used in anesthesiology, fatalities from failure to recognize this technical error did not occur. Respiration was not routinely controlled as it is today, and patients breathed spontaneously throughout maintenance of anesthesia. If esopha- geal intubation occurred, the patient would even- tually recover from anesthesia and attempt to breathe, Sometimes patients would phonate and even talk, In many instances, tracheal reflexes would be activated as the tube entered the larynx or suctioning was performed after intubation. The patient would “react” to the tube and “buck” or cough. There was no doubt about placement when this occurred. When controlled respiration was necessary, apnea was induced by using a narcotic premedicant and cyclopropane, and hyperinflating the lungs. The narcotic preme: cant and the cyclopropane depressed respiration and facilitated induction of apnea. When cyclopro- pane was used, the inspiratory reflexes mediated by pulmonary receptors, coupled with overinfla- tion, inhibited inspiration. It was impossible to induce apnea if the tube was not in the trachea, Today, total muscle paralysis with a neuromuscu- lar blocking agent is commonplace not only in 1592 anesthesiology but for respiratory therapy and other nonsurgical purposes. Patients are no longer allowed to breathe spontaneously during anesthe- sia, “Bucking”? and coughing seldom oceur. If misplacement of the tube is not promptly recognized, the ultimate result is asphyxia. The majority of the cases reviewed in which this type of catastrophe has occurred have been in the hands of nonphysician personnel or unsupervised, inex- perienced residents, but “experienced” anesthesi- logists and emergency room physicians have not been immune. The “bilateral breath sounds” that are universally relied upon for confirmation can be misleading. ‘“Swishing” sounds from the esophagus may be transmitted throughout the thorax and mistaken for breath sounds. Few anesthetists auscultate the chest before they intubate, and thus they have no reference point or anything with which to make a comparison when they rely upon auscultation. Breath sounds before and after intubation should be identical. If breath sounds are not clearly audible, ausculta- tion should not be relied upon to verify proper tube placement. MOUTH-TO-TUBE INSUFFLATION A practically foolproof trick I learned and have used since I was a resicient to verify proper place- ment is to blow into the endotracheal tube and insufflate the lungs with my own expired air immediately after intubation. I pass this on to anyone who may choose to use it. Surprisingly, not many know or think of it. One takes a deep breath and places the lips to the connector and exhales forcefully and quickly into the tube. I mentioned this method in my textbook Techniques and Procedures of Anesthesia,® first published in 1947 and now out of print. Most of the time, the maneu- ver is not necessary because proper placement is obvious. If the rise and fall of the thorax with each compression of the ventilating bag is unimpeded and visible, then one has confirmatory evidence of proper placement. The ‘‘educated hand” of most anesthetists can usually detect the slight increase in resistance as the tube is directed into the rigid cartilaginous structure of the larynx. If the intubation has been difficult, and one is not sure of proper placement, then one should insufllate the tube immediately’ after withdrawing the laryngoscope and inserting the bite block. Intubation does not always assure a patent air- way, and this simple maneuver confirms whether or not the airway is patent. If some impediment in the airway precludes inflating a patient’s lungs by oral insufllation, neither will the patient be able to inspire freely. The force of insufflation is gradually expended in expanding the lungs. The December 1986 + SOUTHERN MEDICAL JOURNAL * Vol. 79, No. 12situation is similar to inflating a balloon. A balloon does not inflate instantly. If the tube is in the esophagus, the operator’s expiratory force is ex- pended abruptly, and low-pitched sounds similar to that of blowing into a hollow tube are elicited. Less time is required to forcefully exhale into the esophagus than to inflate the lungs. On occasions when the tube is in the esophagus, mucus in the pharynx and esophagus may be ejected from the mouth onto the operator’s face by the expired air escaping around the tube, so that immediately after insufflation, the face should be directed close to the connector so that the gases exhaled from the patient's lungs strike the cheek. One can then feel the warmth of the expired air, and if the pa- tient is receiving an inhalation anesthetic that has an odor, such as halothane, or enflurane, one can smell it. If the tube is in the esophagus, one feels no warmth and smells nothing. Although this maneuver may be repulsive to some, it can be lifesaving. I do not rely upon the stethoscope to verify proper tracheal tube place- ment. I use auscultation only to determine whether the tube is in the right bronchus, in which case the right upper lobe of the lung is not aerated. No doubt infection committees, environmen- talists, and others might look with askance upon this maneuver. No one can deny that hepatitis, AIDS, and other infectious diseases might be transmitted to a patient, or that the operator is exposed to any disease the patient might have However, it is as justifiable to execute this maneuver when proper placement of a tube is in doubt as it is to institute mouth-to-mouth breathing in an apneic patient. Protection can be afforded both the patient and the operator by interposing a piece of gauze over the connector before breathing into the tube, or by attaching to the en- dotracheal tube one of the two-way disposable bacterial filters that are now available. Mouth-to-tube insufflation can be used by others besides anesthetists who intubate patients in areas other than the surgical suite, such as emergency and recovery rooms, intensive care units, scenes of accidents, and other areas where itubations must be quickly performed. Although itis seldom necessary when intubating infants and children, ifit is used, expiratory force and volume should be reduced proportionately. ‘Adtiani OTHER METHODS OF VERIFICATION Other methods of verifying placement of tracheal tubes have been advocated, such as analyzers and detectors of end-expired carbon dioxide, since gases returning from the esophagus contain no carbon dioxide. These devices, how- ever, are not in widespread use and often are not immediately available. If they are, determinations sometimes cannot be made quickly. Furthermore, negative findings sometimes create doubt. Under those circumstances, one wonders whether the apparatus is functioning properly. Pulse oximeters are useful also, but oxygen saturation may not decrease promptly in patients who have been preoxygenated. Some anesthesiologists rely on a differential in resistance in compressing the bag, claiming that more resistance is encountered when the tube is in the esophagus than when itis in the Jung. I find the reverse to be the case. Bulging of the epigastrium is an obvious sign of misplace- ment of the tube, but it is not readily apparent in obese patients It is useless to administer atropine and other anticholinergics or ephedrine to overcome brady- cardia and hypotension in the face of obvious hypoxia. Anticholinergics are effective only when bradycardia is due to vagal hyperactivity, and this, occurs infrequently. Nothing that is contained in a syringe takes the place of much-needed oxygen ‘SUMMARY ‘Unrecognized esophageal placement of endo- tracheal tubes during general anesthesia or in apneic unanesthetized patients is not an uncom- mon occurrence. Allowing this mishap to proceed to asphyxia and catastrophe is inexcusable, If one is uncertain, proper placement can be quickly verified by mouth-to-tube insufflation of a sub- Jject’s lungs with one’s own expired air immediate- ly after intubation. This method of verification may be useful in areas other than the operating room, where intubations are performed for resuscitation or airway control References 1. Pierse BC: Presidential addres. American Society of Ancesiologias, ‘lana, Ga Ociber 1988 2. Pierce BC, Cooper JB: Analysis anesthetic mishaps. Jat Amel Cl te SS. Adan J: Techuigues and Pee of Actes. Springfield, 1, Charles Chemise, It Ed, 1947, pp 126-20 MISPLACEMENT OF ENDOTRACHEAL TUBES 1583,