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.
Latresia Tillett
2023
Emergency reintubation for management of laryngospasm: the patient was extubated at 3:07pm following uneventful elective breast reconstruction surgery but subsequently developed laryngospasm and became hypoxic. Attempts were made to mask ventilate with an oropharyngeal airway, followed by placement of a supraglottic airway. The decision was made to reintubate the patient. A grade 2 view of the glottis was reported using a Mac 3 direct laryngoscope and a 7.0 tube was inserted at 3:18pm. Following intubation, both the anesthesiologist and nurse anesthetist confirmed the presence of coarse bilateral breath sounds in the axillae. At 3:23 the position of the tube was checked using a videolaryngoscope and it was reported that it could be seen between the vocal cords.
Two minutes later the patient suffered a cardiac arrest due to pulseless electrical activity and cardiopulmonary resuscitation was commenced. When placing a trans-esophageal echocardiography probe it was noted that the tube was in the oesophagus. The patient was reintubated using a videolaryngoscope, 14 mins after the initial esophageal intubation. Spontaneous circulation was restored 2 mins later.
The patient was transferred ventilated to the intensive care unit where she was treated for several days for cerebral edema before being diagnosed as brain dead.
Sha-asia semple
2020
Emergency intubation following total spinal: following insertion of an epidural catheter for labour analgesia, the patient became unconscious due to a total spinal anaesthetic. An emergency intubation was performed but the tube was placed in the oesophagus. It was 29 minutes before the misplaced tube was identified and the patient’s trachea was successfully intubated. The patient died.
Drew HUghes
2013
Intubation for transport following head injury: the following is a summary of the case published in Intensive Care Research and details published online by the patient’s father, available via the links above.
The 13 year old patient suffered a head injury while skateboarding. Following a CT scan, the decision was made to transfer the patient to another hospital. As a precautionary measure, the patient was electively intubated in the emergency department prior to transfer. Following intubation the patient’s sedation and paralysis wore off and he self-extubated in the emergency department. He was administered further sedation and reintubated prior to commencing transport. During transport the patient again self-extubated, having become aware enough to grab the paramedic’s arm and bite the finger of the respiratory therapist. He was administered vecuronium without further sedation and received 3 minutes of facemask ventilation, before again being reintubated by the respiratory therapist.
Capnography was not used to confirm correct placement of the tube. Following intubation, the patient’s oxygen saturation, which had been in the high 90’s, rapidly deteriorated, reaching 40% by 3 mins after intubation. The ambulance crew called the emergency department to report that the tube had become dislodged, saying that although the patient had been reintubated their oxygen saturation remained low, and that they may have aspirated. Five minutes after intubation the patient became severely bradycardic and pulseless. The emergency department doctor asked the ambulance crew to recheck and suction the tube, suggesting that the cardiac arrest was more likely to have a respiratory aetiology, but the tube remained in situ.
The ambulance diverted to a nearby hospital where oesophageal placement of the tube was promptly recognised and the patient was reintubated. The patient had not been ventilated for at least 30 minutes while the tube was placed in the oesophagus. No brain activity could be identified and the patient died.
Anaesthesia closed claims database
1995 - 2013
45 CASES: the following is a brief summary of some of the cases described in the case series report published in Anaesthesia & Analgesia, available via the link above.
Respiratory compromise after cystoscopy: Following a cystoscopy, a 50 year old patient developed respiratory insufficiency during transport from the operating room and had arrested on arrival in the post-anaesthesia recovery area. The patient was reintubated by the anesthesiologist who observed the tube pass through the cords. The recovery nurse noted coarse breath sounds on chest auscultation. An emergency physician present noted the lack of a capnography trace, the absence of breath sounds in the lungs and audible breath sounds over the abdomen but was unable to convince the anesthesiologist to replace the tube. Chest x-ray subsequently demonstrated oesophageal intubation. Following reintubation a capnography trace was obtained and spontaneous circulation was restored. He was transferred to intensive care and died.
Evacuation of neck haematoma: A 45 year old patient returned to the operating room for evacuation of a neck haematoma. Following a difficult laryngoscopy the tube was placed. A capnography trace was briefly obtained but disappeared within a minute followed by the patient arresting. During cardiac life support the tube was replaced and a normal capnography trace obtained but the patient sustained brain damage.
Embolisation of splenic artery: A 50 year old patient was intubated in interventional radiology suite for an urgent splenic artery embolisation. The anesthesiologist performing the intubation saw the tube pass between the vocal cords. Colorimetric carbon dioxide detection was used but changed colour slowly. This was accompanied by bradycardia so the tube was removed and facemask ventilation performed before reintubating. Again the anesthesiologist saw the tube pass between the vocal cords and the carbon dioxide detector changed colour slowly. Multiple clinicians auscultated the lungs. Bradycardia recurred but was attributed to bleeding. The patient was transferred to the operating room. At laparotomy, no bleeding was identified but the stomach was ruptured with air coming from it with ventilation. The patient died.
General anaesthesia for elective thyroidectomy: A 60 year old patient was intubated for a thyroidectomy. No capnography trace was obtained but this was thought be due to a malfunction of the monitor. Lung auscultation revealed bilateral breath sounds and there was no sounds audible over the epigastrium. The oxygen saturation deteriorated and heart rate slowed over the next 10 minutes before the patient became severely bradycardic and arrested. Cardiac life support was initiated. The patient was extubated and facemask ventilation commenced. Oxygen saturation returned to normal and a capnography trace was obtained, though the amplitude was severely attenuated. Cardiac life support continued and reintubation was performed 20 minutes after the initial intubation. Approximately 13 minutes after reintubation the capnography amplitude returned to normal levels. The patient sustained hypoxic brain damage and did not regain consciousness.
Cauterisation of nasal bleeding: A 40 year old patient was intubated for cauterisation of nasal bleeding after sinus surgery. Wheezing was noted on lung auscultation, more marked on the right side, associated with deteriorating oxygen saturation and falling exhaled carbon dioxide levels. Treatment for bronchospasm was initiated. After 10-15 minutes the patient was reintubated and subsequently developed bradycardia. A code was called and vital signs restored after 10 minutes. Surgery was then performed. The patient did not wake and died 2 months later.
Sedation for cardiac catheterisation: A 75 year old patient was sedated by cath lab nurses for cardiac catheterisation. Approximately 4 mins after coronary angioplasty the patient became hypotensive, bradycardic and apnoea. Facemask ventilation and cardiac life support was commenced and a pacing wire placed. An anesthesiologist arrived and intubated the patient. The capnography trace was low amplitude but misting of the tube was noted and the cardiologist was able to hear breath sounds. The patient was cyanotic, and continued to require cardiac life support. Over a period of 17 minutes, arterial blood gases repeatedly demonstrated a PO2 of 6-8 mmHg and a PCO2 in excess of 100 mmHg. A second anesthesiologist attended and reintubated the patient, rapidly restoring blood oxygen levels. The patient died.
Cardiac arrest in intensive care unit: A 20 year old patient arrested following intubation in the intensive care unit. The responding anesthesiologist noted clear signs of oesophageal intubation but the emergency physician refused to allow the anesthesiologist to perform a check laryngoscopy, instead repeating the laryngoscopy themselves. Following over 10 minutes of heated discussion, the emergency physician allowed the anesthesiologist to check the position of the tube via laryngoscopy and it was found to be in the oesophagus. The patient was reintubated without incident but sustained severe hypoxic brain injury and died.