Preventing unrecognised oesophageal intubation

CONSENSUS GUIDELINE

PUMA Large.jpg

Click on image to access paper

This special standalone PUMA guideline was developed in consultation with the world’s major airway societies to urgently address the ongoing issue of unrecognised oesophageal intubation.

This special article explores the issue of unrecognised oesophageal intubation & the PUMA consensus guideline recommendations from an emergency perspective.

This data in this review reveals the inadequate discriminatory value of clinical examination findings for excluding oesophageal intubation.

 
 
 
 
 
 
 
 
 
 
 
 

AETIOLOGY

Of UNRECOGNISED OESOPHAGEAL INTUBATION

The table below is an expanded version of Table 1 from the ‘Preventing unrecognised oesophageal intubation’ consensus guidelines

Expanded version of Table 1 from the guideline

CASES

OF UNRECOGNISED OESOPHAGEAL INTUBATION

The following are actual cases of unrecognised oesophageal intubation, the details of which are publicly available. Links are provided to the source material. These cases are provided to enhance airway practitioners’ understanding of how such events occur and the importance of adopting the strategies advocated to prevent them. The intent of highlighting these cases is to highlight common themes and foster appreciation of how any airway practitioner might become vulnerable to taking similar actions in situations of stress, not to invite criticism of the individuals involved. We extend our sympathy to the family and friends of the patients harmed in these tragic incidents.

If you are aware of other publicly available cases of unrecognised oesophageal intubation that can be added to this catalogue, please contact us with a link to the published details of the case. Please do not submit cases if the details are only available to you via privileged communication.

Australia

 

New Zealand

 

United Kingdom

 

United States

SUPPORT

FOR THE CONSENSUS GUIDELINES FOR PREVENTING UNRECOGNISED OESOPHAGEAL INTUBATION

The organisations listed below have declared their support for the ‘Preventing unrecognised oesophageal intubation’ consensus guidelines

As some organisations have strict criteria that prevent them ‘endorsing’ the work of other organisations, even when in full agreement with the content, only the airway societies involved in authoring the guidelines were given the opportunity to provide endorsement. All other organisations have simply been invited to declare their support for the guidelines. The list of supporting organisations below will be updated as more organisations complete their own internal processes for making this decision. If your organisation would like to support these guidelines please contact us.

Endorsement

‘Prevention of unrecognised oesophageal intubation: consensus guideline from the Project for Universal Management of Airways and international Airway Societies’ has been endorsed by the following airway societies.


 
 

Difficult Airway Society

Society for Airway Management

European Airway Management Society

All India Difficult Airway Association

Canadian Airway Focus Group

Safe Airway Society

International Airway Management Society

 
 
 

GCAP

Global capnography project

The Global Capnography Project was established in 2016 to evaluate and improve access to the training and equipment required for use of capnography during airway management in low resource settings. It was hoped that this would improve patient safety through early recognition of critical airway incidents. In the six months following initial provision of capnography monitors and training in waveform interpretation in eight hospitals in Malawi, Africa, anaesthesia providers reported recognising 44 oesophageal intubations.

 

To support the Global Capnography Project, please click the button below to make a donation.