PROBLEMS RELATED TO THE ENDOTRACHEAL-TUBE - AN ANALYSIS OF 2000 INCIDENT REPORTS

The first 2000 incidents reported to the Australian Incident Monitorin g Study were analysed with respect to problems with the endotracheal t ube; 189 (9%) were reported. The most common problem was endobronchial intubation which accounted for 42% of these 189 reports, endobronchia l intubation was the most common cause of arterial desaturation in the 2000 incidents. Obstructions and oesophageal intubation each accounte d for 18% of the 189 problems with tubes. The remainder was made up of disconnections and leaks (7% each), misplacements other than endobron chial or oesophageal (4%), inappropriate choice of tube (3%), cuff her niation (1%), failure to deflate the cuff and foreign body in the tube (0.5% each). The pulse oximeter and capnograph first detected 58% of these incidents; a further 25% were detected clinically. The pulse oxi meter is the ''front-line'' monitor for endobronchial intubation, and the capnograph the ''front-line'' monitor for oesophageal intubation, disconnection and obstruction. Recommendations are made for how to pre vent problems and how to determine the nature of those that do occur.