ESOPHAGEAL INTUBATION - AN ANALYSIS OF 2000 INCIDENT REPORTS

There were 35 oesophageal intubations in the first 2000 incidents repo rted to the Australian Incident Monitoring Study (AIMS). These reports confirm existing impressions that misplacement of the endotracheal tu be can occur in trained as well as untrained hands, and that auscultat ion is an unreliable test. On the other hand, the value of capnography is emphasised, with no false positives in the 16 cases in which the i nstrument was used. There was one false negative. Over the 4 years of the AIMS study, reports have declined in frequency. It is possible tha t the early detection of oesophageal intubation by capnography has alt ered its status to the extent that anaesthetists no longer regard it a s a ''critical'' incident. It is highly recommended that the presence of the expected concentration of carbon dioxide in expired air be conf irmed by capnography immediately after any endotracheal intubation.