The following are actual cases of unrecognised oesophageal intubation, the details of which are publicly available. 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.
Patient XH
2019
General anaesthesia for elective inguinal hernia repair: the following is a summary of the coroner’s findings available via the link above.
The 46 year old patient presented for an elective inguinal hernia repair. The patient’s past history included obstructive sleep apnoea and asthma. On clinical examination the patient was assessed as being potentially challenging both to intubate and facemask ventilate due to poor dentition, full beard, increased neck circumference and Mallampati score of 3.
Following induction with fentanyl, propofol and suxamethonium, the patient was intubated uneventfully using a videolaryngoscope which provided a grade 1 Cormack-Lehane view. The tube was visualised passing between the vocal cords on the videolaryngoscope screen by the consultant anaesthetist, anaesthetic nurse and a theatre technician. Exhaled carbon dioxide was initially present but from the outset ventilation was difficult, requiring high pressures, with the collapsible flow-inflating bag described as ‘tight like a brick’. There was associated skin erythema. Oxygen saturations rapidly deteriorated to 40%. The emergency buzzer was pressed and management for bronchospasm/anaphylaxis was initiated.
A second consultant anaesthetist attended immediately and auscultated the chest, reporting hearing breath sounds and crackles. Misting of the tube with exhalation was noted. Exhaled carbon dioxide was noted to be present but with a reduced amplitude of about 10 mmHg (1.3 kPa). The patient’s face was noted to be swollen. Shortly afterwards the patient became pulseless and cardiac life support was initiated. At this stage the first consultant noticed a sudden loss of pressure in the previously tense flow-inflating bag, prompting a check of the anaesthetic machine, but no issues were identified. A third consultant anaesthetist entered the operating theatre approximately 5 minutes after the onset of cardiac arrest.
Concerns were raised regarding the position of the tube. The primary anaesthetist attempted to assess the position of the tube using repeat videolaryngoscopy on two occasions but felt this could not be undertaken safely due to the movement caused by chest compressions. Lung auscultation was used on two further occasions to assess the position of the tube, with the presence of breath sounds interpreted as providing reassurance that it was correctly placed in the trachea.
There was a return of spontaneous circulation approximately 14 minutes after the onset of cardiac arrest. A fourth consultant anaesthetist entered around this time and noted the patient to be deeply cyanosed with a very distended abdomen. The monitor at this time showed no capnography trace. The fourth anaesthetist performed repeat laryngoscopy and finding the tube to be in the oesophagus, removed it and successfully reintubated the patient. A normal capnography trace was obtained with carbon dioxide levels of 70 mmHg (9.3 kPa). Peak airway pressures returned to high levels following successful reintubation.
Subsequent MRI revealed severe hypoxic cortical injury and the patient was declared brain dead a week later.
Emiliana Obusan
2019
General anaesthesia for repair of finger laceration: the following is a summary of the coroner’s findings available via the link above.
Shortly after 17:30, the 19 month old, otherwise well patient, was anaesthetised for debridement and repair of a de-gloving laceration of their right middle finger. Intubation was planned due to an increased aspiration risk but the intention was to avoid use of neuromuscular blocking agents due to the brevity of the procedure and the potential complications associated with these medications.
Upon placing the facemask on the patient, the anaesthetic registrar noted that the capnography was not working. The sample line was found to be loose and upon tightening, a capnography waveform was displayed. The anaesthetic consultant (who had recently completed his fellowship) administered fentanyl and propofol. The anaesthetic registrar confirmed the ability to ventilate the patient with a facemask before performing laryngoscopy. Initially only about 20% of the glottis was visible but this improved to 60% exposure of the vocal cords with external laryngeal manipulation. This view was verbalised by the anaesthetic registrar and a size 4 cuffed tracheal tube was inserted to a depth of 15cm. The anaesthetic registrar was certain that he saw the tube pass through the glottic opening into the trachea. Despite cuff inflation an air leak was audible with manual ventilation and persisted despite additional cuff inflation. Bilateral chest rise and tube misting with manual ventilation were observed by both the anaesthetic registrar and consultant but the patient’s oxygen saturation rapidly fell below 90%. While a capnography trace was noted to be present, it was low amplitude with a ‘sawtooth’ morphology, though no significance was placed on this at the time by the anaesthetic registrar. The anaesthetic consultant felt that the low carbon dioxide readings could be explained by recurrence of the previously encountered issue with the loose sample line or by bronchospasm.
The anaesthetic consultant took over management of the airway, withdrew the tube to 12 cm and requested the attendance of another more senior anaesthetic consultant, with whom he had previously discussed the case. The anaesthetic registrar confirmed the presence of bilateral breath sounds on lung auscultation, as well as coarse wheezing sounds thought to originate in the upper airway. There was no improvement in the cuff leak and the feel of the bag of the paediatric circuit suggested a compromised ability generate inspiratory pressure. However, chest rise/fall appeared more pronounced and the oxygen saturation gradually improved to around 95% which the anaesthetic consultant interpreted as indicating correct placement of the tube.
The second, senior consultant anaesthetist arrived promptly and the issues encountered were communicated to them. The decision was made to remove the tube and replace it with a larger one to improve ventilation. Prior to removal of the first tube, repeat direct laryngoscopy was performed by the first consultant anaesthetist. Following manipulation he was able to achieve a grade 2a Cormack-Lehane view and observed that the first tube was passing between the vocal cords. Following removal of the first tube, which was noted by the anaesthetic nurse to have blood near its tip, the first consultant anaesthetist ultimately obtained a 2a view of the larynx. A size 4.5 tube was inserted to a depth of 12cm and the first anaesthetic consultant reported being certain of seeing the tube pass between the vocal cords without difficulty. After cuff inflation there was no leak present for the first few breaths, which were observed to be associated with carbon dioxide waveforms. Following this an audible air leak recurred, though smaller than that with the original tube. Lung auscultation by each of the doctors indicated the presence of bilateral breath sounds accompanied by a harsh wheeze. Around ten carbon dioxide waveforms of low/minimal amplitude were subsequently observed, which the first consultant anaesthetist interpreted as being consistent with the wheeze present on lung auscultation. Later review of the trend printout was unable to identify any readings consistent with carbon dioxide levels above 3mmHg following induction. The patient’s oxygen saturation had fallen to around 80% and their stomach was noted to be distended. Unable to reconcile these clinical signs with correct placement of the tube, the senior anaesthetic consultant asked if the tube was in and reported that the first consultant and registrar both replied that it was, though neither has any recollection of this exchange. The situation at this stage was described as chaotic with lots of information to process. The paediatric breathing circuit was noted to be at high pressure and the second anaesthetic consultant took steps to address this, as well as passing a suction catheter to decompress the stomach. No further attempts to exclude oesophageal intubation using a laryngoscope, flexible bronchoscope or by removal of the tube and ventilation with a facemask or supraglottic airway, were undertaken.
Just over 15 minutes after the initial intubation a third anaesthetic consultant was asked to come to the theatre and arrived within a few minutes. The third anaesthetic consultant auscultated the patient’s chest, again hearing breath sounds and wheeze. They also noted the presence of abdominal distention and an audible air leak around the tube. The cuff pressure was checked, found to be high and was reduced.
The possibility of bronchospasm/anaphylaxis was suggested and appropriate treatment commenced. The anaesthetic was also deepened and suxamethonium administered to improve ventilation. The patient’s oxygen saturation and heart rate then dropped precipitously. There was no response to atropine. A cardiac arrest was declared and cardiac life support initiated. The second consultant anaesthetist reported shouting “We need to take the tube out” immediately after the cardiac arrest was declared but could not recall receiving any response to this declaration. Again the chaotic and stressful nature of events at this time was emphasised. Following a brief return of spontaneous circulation the patient became asystolic and cardiac life support continued. Multiple other staff members entered the operating theatre. An ultrasound was performed to exclude pneumothorax and the suggestion was raised that the patient might have a tracheo-oeophageal fistula.
Approximately 20 mins after the onset of cardiac arrest, a paediatrician who had become involved in resuscitation efforts contacted the paediatric transport service at the local children’s hospital and discussed the case with a paediatric retrieval consultant and paediatric intensivists. The retrieval consultant asked if the airway was definitely in the right place and whether this had been confirmed with colorimetry.
After over 40 minutes of cardiac life support, further resuscitation attempts were deemed futile and the patient was declared dead just over one hour after induction of anaesthesia.
A post-mortem radiology report described the tube as terminating in the oesophagus at the level of the third thoracic vertebra. At post-mortem examination, a superficial tear 10mm in length was noted in the oesophageal mucosa, just above the level of the hilum of the lung. Areas of haemorrhage were also present in the upper third of the oesophagus. These findings, along with the blood on the tip of the first tube, were considered to support the conclusion that both intubations had resulted in unrecognised oesophageal placement of the tube, either primarily or due to subsequent migration. A mast cell tryptase was within normal limits.
Anonymous
2016
Sedation for elective gastroscopy: the following is a summary of a case reported in A&A Practice accessible via the link above, supplemented by information obtained through personal communication with the authors, with the permission of the patient’s family.
A 78 year old woman with a past history of mild asthma was admitted to hospital with gastrointestinal bleeding and anaemia. She was transfused and was scheduled for an emergency gastroscopy the next day. The hospital had recently introduced use of carbon dioxide for insufflation during upper gastrointestinal endoscopic procedures. Many anaesthetic staff, including the senior anaesthetic registrar managing the case, were not aware of this change. The patient’s airway was assessed as being potentially challenging to manage due to their body habitus and a previous cervical fusion.
The patient underwent deep sedation with propofol in the left lateral position as is routine for gastroscopies in Australia. Following introduction of the gastroscope the patient’s oxygen saturation rapidly dropped to around 80%. The gastroscope was immediately withdrawn and the patient rolled supine. Facemask ventilation was attempted with 100% oxygen but was difficult. A diagnosis of laryngospasm was considered and suxamethonium was administered to improve facemask ventilation. The oxygen saturation transiently improved to the low 90’s before falling again. The senior anaesthetic registrar decided to intubate the patient. Using a direct laryngoscope, intubation was challenging, with a grade 3 Cormack-Lehane view being the best obtained despite external laryngeal manipulation. The tube was inserted using a bougie but the vocal cords were never seen. Large amplitude exhaled carbon dioxide waveforms were obtained for the first four breaths following intubation, which was interpreted as reflecting successful tracheal placement of the tube. Rather than the locally used units of mmHg, the monitor being used was incorrectly configured to display the carbon dioxide level in unfamiliar units of kPa, making it difficult for the senior anaesthetic registrar to interpret the absolute value of the waveform amplitude. The capnography waveform subsequently tapered off abruptly and the pulse oximetry trace was lost, which was attributed to the concurrent onset of cardiac arrest, associated with a narrow complex ECG at a rate of around 20/min. An emergency was declared and cardiac life support promptly commenced.
A number of staff arrived in a staggered fashion in response to the code blue call including multiple nurses, a second gastroenterologist, another anaesthetic registrar and four anaesthetic consultants. The second anaesthetic registrar noted the absence of a capnography trace on their arrival and asked whether the tube was correctly placed. They were advised that there had been good carbon dioxide return prior to the loss of cardiac output. The first anaesthetic consultant arrived from elsewhere in the hospital several minutes after the code blue call. It was communicated to them by the first anaesthetic registrar, that due to respiratory difficulties the patient had been intubated and that tracheal placement of the tube had been confirmed by good amplitude exhaled carbon dioxide return over several breaths prior to the cardiac arrest but that subsequently carbon dioxide levels had rapidly declined. The first anaesthetic consultant noted that no capnography or oximetry traces were present at that time. When the second and third anaesthetic consultants arrived shortly afterwards, the first consultant anaesthetist explained to them that confirmation of tracheal placement of the tube had been confirmed by capnography prior to the patient arresting. The first anaesthetic consultant performed a physical examination to evaluate the cause of the initial respiratory deterioration and arrest. Good chest rise and fall with ventilation and and the presence of breath sounds were noted on lung ausculation. A fourth anaesthetic consultant then arrived and took over the leadership role from the first anaesthetic consultant. Potential precipitants for the cardiac arrest, including a primary cardiac event, hypovolaemia and anaphylaxis, were discussed amongst the anaesthetic staff as resuscitation proceeded.
Following approximately 7 minutes of resuscitation, spontaneous circulation was restored. The ECG showed a narrow complex rhythm with a rate of around 50/min associated with a weak pulse. However, other than occasional small ‘blips’ the capnograph continued to read zero and there was no detectable pulse oximetry trace. This was attributed to persistent poor cardiac output and possible bronchospasm. There was some difficulty hand ventilating the patient due to high pressures and the possibility of anaphylaxis was suggested by one of the anaesthetic consultants. The other anaesthetic consultants agreed this was a possibility and treatment for this was commenced. The lungs were again auscultated at the direction of the fourth anaesthetic consultant. Breath sounds were noted to be difficult to hear in the noisy room but were thought to be present. The patient’s abdomen appeared distended so a brief attempt was made to pass a nasogastric tube and deflate the stomach but this was unsuccessful. Functioning of the capnograph was confirmed by disconnecting and blowing into the sampling line, which produced a normal capnography waveform.
Due to the persistent poor carbon dioxide trace when ventilating the patient, the fourth anaesthetic consultant removed the tube. Facemask ventilation was commenced which was moderately difficult but produced a good capnography trace. The trachea was then successfully intubated over a bougie, with a grade 2b view being achieved using direct laryngoscopy. Tracheal position of the tube was confirmed by a sustained carbon dioxide trace and oxygen saturations improved to 100%.
The patient was estimated to have been deprived of oxygen for a total of approximately 15 minutes between the initial desaturation and successful tracheal intubation.
The patient was transferred to the intensive care unit. Support was withdrawn 5 days later, following diagnosis of brain death. At autopsy the cause of death was identified as ‘global cerebral ischaemic injury’.
Sukana Thurairajah
2011
Emergency call in dialysis unit: the following is a summary of the findings of the coroner’s findings available via the link above.
During the mid-afternoon, a 55 year old obese patient with multiple medical problems, developed respiratory distress during haemodialysis and became progressively obtunded over the next hour. A medical emergency was called. Around 15 people attended the bedside including a first year anaesthetic registrar, the intensive care registrar, the intensive care resident, the consultant nephrologist and multiple nursing staff. The intensive care registrar assumed a leadership role and as the patient was unresponsive, declared the need to intubate. When the first year anaesthetic registrar arrived the intensive care registrar directed them to assist the patient’s breathing using a bag and mask during a delay while blood results were obtained to determine the patient’s potassium level.
The anaesthetic registrar was assigned to intubate. While the anaesthetic registrar had some experience intubating in a controlled theatre environment, this was the first time they had performed an emergency intubation. The intensive care registrar and resident actually had significantly more experience performing emergency intubations but the intensive care registrar was unaware of this and no discussion took place to clarify the relative experience with airway management of the doctors present. Propofol and suxamethonium were administered. There was difficulty obtaining a view of the vocal cords and a bougie was passed blindly. The anaesthetic registar requested several times for someone to railroad the tube over the bougie, but when no one responded, they removed the laryngoscope and passed the tube blindly themselves. Intubation was completed approximately 15 minutes after the emergency call was made. A second laryngoscopy was performed after railroading of the tube to assess tube placement but the anaesthetic registrar was again unable to visualise the vocal cords. Tube placement was evaluated by the the intensive care resident and consultant, using lung auscultation which confirmed bilateral breath sounds. Misting of the tube with exhalation was observed by the anaesthetic registrar as well as some vomitus in the tube, which was attributed to the patient having recently vomited. One of the nurses expressed concern that the patient’s abdomen was distended and that the patient had become flatulant. The intensive care registrar agreed with this observation but considered it was difficult to assess given the patient’s body habitus. Another nurse also noted the abdominal distention but did not verbalise this.
Several minutes elapsed before carbon dioxide monitoring was connected due to prioritisation of other aspects of resuscitation, a subsequent delay or around 5 minutes while the capnograph ‘warmed up’ and an understanding that tracheal placement of the tube had already been confirmed by auscultation. Colorimetric carbon dioxide detection was eventually attached in the interim and both the anaesthetic registrar and the nurse who attached it, noticed that it did not demonstrate any colour change. The nurse thought this may have been due to the sensor material becoming wet. The anaesthetic registrar believed that capnography was unavailable and the intensive care registrar was unaware that any carbon dioxide monitoring was available at all. The anaesthetic and intensive care doctors acknowledged that they were unfamiliar with the contents of the emergency trolley and the operation of the capnography monitor on it.
Within a few minutes of intubation the patient became bradycardic and cardiac life support was commenced.
One of the nurses, concerned about the patient’s condition, requested the senior intensive care registrar to attend. Upon arriving around 5 minutes after the commencement of cardiac life support, the senior intensive care registrar noted, for the first time, the absence of any pulse oximetry or carbon dioxide trace and queried the position of the tube. The anaesthetic registrar performed repeat laryngoscopy and confirmed that it was correctly placed. The senior intensive care registrar asked the first intensive care registrar to perform an additional laryngoscopy to obtain an independent assessment of the tube position. This second repeat laryngoscopy revealed the tube to be positioned in the oesophagus and the patient was reintubated. Spontaneous circulation was rapidly restored. At least 18 minutes elapsed between the initial oesophageal intubation and the second intubation.
The patient was transferred to the intensive care unit where it was determined they had suffered severe hypoxic neurological injury. Having made no significant neurological recovery tend days later, the decision was made to withdraw treatment and the patient died.
RUBEN CHAND
2009
Failed trial of extubation: the following is a summary of the findings of the coroner’s findings available via the link above.
The patient had been intubated following a cardiac arrest and subsequently underwent coronary artery bypass surgery, before being transferred to another hospital for ongoing care in the intensive care unit. Five days later, the decision was made by the intensive care consultant to extubate the patient. Although the patient had been noted to be challenging to intubate at the original hospital, this information had not been communicated to the receiving hospital.
The patient was extubated by the intensive care nursing staff at around 11:40am but due to deteriorating respiratory and neurological state over the following 50 minutes, the decision was made by the senior intensive care registrar to reintubate. This decision was not communicated to the intensive care consultant. The intensive care nurse felt that preparation for intubation was rushed and disorganised with poor task allocation. Preoxygenation with a bag & mask was attempted but was sub-optimal due to patient agitation impeding a facemask seal. Patient movement also made it difficult to get a pulse oximetry reading. The initial attempt at intubation was undertaken by the junior intensive care registar, who was unable to pass the tube despite a view of the cords. At around 12:40pm, the senior intensive care registrar took over management of the airway. No intervening attempt at facemask ventilation was made prior to repeating laryngoscopy, which achieved between a 2b & 3 Cormack-Lehane view. A bougie was requested but despite the bougie being available, a different type of introducer was provided instead. Rather than ask again for the bougie, the senior intensive care registrar instead decided to pass the tube without it, which was difficult. During the course of the second intubation attempt, the intensive care nurse verbalised that there was no oxygen saturation reading and that the patient was bradycardic with deteriorating blood pressure but still no facemask ventilation was undertaken. Following passage of the tube, tube misting and chest rise with ventilation was observed by both the senior and junior intensive care registrars. This was interpreted as suggesting correct tube placement but confirmation of this via capnography was not obtained, despite it being connected. The intensive care nurses noticed that the capnography trace obtained was not consistent with tracheal placement.
At 12:47pm, around the time of passage of the tube, the patient suffered a cardiac arrest and cardiac life support was initiated. In response to the cardiac arrest call, two intensive care consultants arrived at the bedside within a minute. It was communicated to them that the patient had been reintubated due to worsening hypoxia but despite this remained hypoxic and had arrested. No mention was made of the difficulties with intubation or the lack of a capnography trace. The intensive care consultants assumed that correct tube placement had initially been confirmed by capnography prior to the onset of cardiac arrest and that the absence of a capnography trace they now noted, was due to the cardiac arrest or a possible tension pneumothorax. As the patient was known to have had a left sided pneumothorax, a needle decompression of the left hemithorax was performed but did not suggest tension pneumothorax. A flexible bronchoscope was requested that revealed the tube to be in the oesophagus. The tube was removed and facemask ventilation commenced, with return of a capnography trace. Laryngoscopy by one of the intensive care consultants achieved a grade 3 view. A bougie was inserted into the oedematous larynx but an 8.0mm tube was unable to be passed over it and the trachea was only able to be successfully intubated after changing to a 7.0mm tube. Return of spontaneous circulation was subsequently achieved. The total period of oxygen deprivation was between 17 - 22 minutes.
Three days later, after a period of therapeutic hypothermia, the patient was weaned off sedation but failed to regain consciousness. An EEG and cerebral perfusion scan revealed no neurological activity and supportive measures where withdrawn a week after the above events. Autopsy revealed hypoxic encephalopathy.
Matthew LYnn
2005
Coughing in intubated patient in intensive care: the following is a summary of the findings of the coroners findings available via the link above.
After midnight, more than 24 hours following straightforward successful tracheal intubation, the 20 year old patient became agitated and started vigorously coughing on their tube in the intensive care unit. Large amounts of bile-stained fluid were suctioned from the tube, which combined with deterioration of the oxygen saturation to 70 -80% on 100% oxygen, raised concerns from the nursing staff about whether it had migrated out of the trachea.
Lung auscultation by the nursing staff was impeded by the patient’s retching but epigastric auscultation suggested that air might have been entering the stomach during hand ventilation. A junior intensive care registrar with significant anaesthetic experience was called to the bedside.
The registrar noted that the abdomen was not distended, that the patient was easy to ventilate by hand that auscultation indicated good air entry bilaterally. The distance of the tube at the teeth was noted to be 22cm, unchanged from that at the time of intubation. Repeat laryngoscopy was reported to reveal a clear view of the the tracheal tube positioned between the vocal cords. No independent assessment of the laryngoscopy findings by another practitioner was undertaken at this time.
On the basis of the above findings it was determined that the tracheal tube was correctly placed. The patient was further sedated but with the exception of a transient improvement to 93%, oxygen saturation remained compromised on 100% oxygen. Hypoxaemia was confirmed on arterial blood gas analysis and attributed to massive aspiration.
Approximately 40 minutes after the onset of events, vecuronium was administered. A second junior intensive care registrar arrived shortly afterwards and confirmed air air entry and crepitations on lung auscultation. Having been advised that tracheal position of the tube had been confirmed, the second registrar concurred with the diagnosis of gastric aspiration. Repeat laryngoscopy was not undertaken by the second registrar at this point and capnography was not used at any stage. Over several minutes following administration of the neuromuscular blocking agent, the patient’s oxygen saturation abruptly deteriorated to critical levels and a previous tachycardia progressed to bradycardia and subsequent cardiac arrest. Cardiac life support was implemented without success. The patient’s abdomen was noted to be distended around this time.
Approximately 20 minutes following the onset of cardiac arrest, in response to prompting by one of the nursing staff, the second registrar performed a repeat laryngoscopy and quickly established the tube was in the oesophagus with the cuff still inflated.
Uneventful tracheal reintubation was successfully performed, after which a normal cardiac rhythm was rapidly restored. The patient suffered significant cerebral hypoxia however, and was declared brain dead a few days later.
Richard Jankowski
2001
Acute airway obstruction in post-anaesthesia care unit: the following is a summary of the coroner’s findings available via the link above.
Just after midday, the senior anaesthetic registrar was called urgently to the post-anaesthesia care unit to review the 39 year old otherwise well patient who was in severe respiratory distress. The patient had been extubated earlier that morning, following surgery for incision and drainage of a dental abscess. While the oxygen saturation was still good on 100% oxygen via a facemask the anaesthetic registrar considered that a respiratory arrest was imminent and instructed the team to prepare for immediate reintubation. Before this could be undertaken the patient suffered complete airway obstruction and the emergency buzzer was pressed. Carbon dioxide monitoring was not immediately available.
Facemask ventilation appeared only to cause stomach distention. Laryngoscopy did not reveal any recognisable structures due to swelling. A bougie was eventually able to be passed blindly and a tracheal tube railroaded over it but it was not clear that the tube had entered the trachea. Lung auscultation by one of the nursing staff was thought to reveal breath sounds with ventilation, and chest movement appeared to be occurring. The intubation was assessed as being successful, the patient sedated and a request made for bed in the intensive care unit. The intensive care senior registrar was asked to attend.
Over the ensuing minutes the patient became bradycardic and atropine was administered. The pulse oximeter was not displaying either a waveform or numerical value and the patient’s colour was not improving with ventilation. Correct placement of the tube was questioned, prompting repeat lung auscultation by the anaesthetic registrar which confirmed the presence of breath sounds. No sounds were heard over the epigastrium with ventilation. While the tube was still believed to be positioned in the trachea, capnography was requested to confirm this.
During the delay while the gas monitor was connected and warmed up, the anaesthetic registrar requested a flexible bronchoscope to evaluate the position of the tube but the device malfunctioned and could not be used. Once ready, the gas monitor detected inspired oxygen but no exhaled carbon dioxide. Abdominal distention was noted at this time but breath sounds were still audible on lung auscultation. Due to apparent doubts about whether the gas monitor was functioning properly, a second carbon dioxide analyser was connected, reconfirming the absence of carbon dioxide in the expired gas and incorrect placement of the tube.
The tube was removed and reintubation attempted without success, approximately 10 minutes following the respiratory arrest. The decision was made to peform neck rescue (“surgical airway”) but two attempts at this by the anaesthetic registrar using a cannula technique were unsuccessful.
Chest compressions were commenced around this time to maintain cardiac output and the arriving intensive care senior registrar immediately requested their consultant to attend urgently. An anaesthetic consultant also arrived and assumed management of the airway, reattempting laryngoscopy using a longer blade, without success. A blind attempt at intubation was made but rapidly abandoned, with plans to reattempt neck rescue. The intensive care consultant arrived at this point and instead placed a supraglottic airway which appeared to restore chest movement but due to doubts about the adequacy of ventilation, neck rescue was performed using a scalpel technique. Success was confirmed with capnography and spontaneous cardiac output was subsequently rapidly restored.
The patient returned to the operating theatre for a surgical tracheostomy and spent three days in the intensive care unit before ventilation was discontinued, the patient having experienced hypoxic brain injury during the period of airway obstruction.