respiratory
resuscitation
practice
paramedic
paramedic

Evaluating the incidence of unrecognised oesophageal intubation by paramedics

08 April 2013
Features
02 April 2013
Volume 5 · Issue 4

Abstract

Objective: To determine the incidence of unrecognised oesophageal intubation by paramedics in a metropolitan setting.

Methods: A retrospective observational analysis was conducted. Patient health care records from the Ambulance Service of New South Wales were used to identify patients who had been intubated by paramedics between 1 January 2007 and 31 December 2010, and transported to St George Hospital, Sydney. Medical records from St George Hospital were reviewed to determine the position of the endotracheal tube (ETT) on arrival in the Emergency Department.

Results: During the study period, 196 patients were identified as having an ETT in-situ on arrival to the emergency department. There was inadequate documentation for 67 patients to determine ETT placement. Of the 129 patients included in the final analysis, 4 (3.1%, 95% confidence interval (CI) 0.9–7.8%) had an unrecognised oesophageal intubation. The final ETT positions of the remaining 125 patients were 85.3% (95% CI 78–90.9%) located in the trachea, 10.1% (95% CI 5.5–16.6%) located in a primary bronchus, 0.8% (95% CI 0–4.2%) in the larynx and 0.8% (95% CI 0–4.2%) in the pharynx.

Conclusion: The incidence of unrecognised oesophageal intubations in this study was consistent with other reports in the literature, although higher than expected given the training and equipment used in this setting. An incidence of unrecognised oesophageal intubations of zero should be the goal of emergency medical services. The incidence of unrecognised oesophageal intubations may be reduced through recursive training programs and the use of quantitative waveform capnography.

The maintenance of a patent airway is a requirement for every patient. In the context of critically ill patients, this is frequently achieved by the use of invasive airway devices. Endotracheal intubation (ETI) is considered the ‘gold standard’ of airway management in the hospital setting (Wang, 2007).

ETI is recommended by the Australian Resuscitation Council for airway maintenance and protection during cardiopulmonary resuscitation (Australian Resuscitation Council, 2010). Since the inception of paramedic practice over 30 years ago paramedics have performed ETI. Early research into paramedic pre-hospital ETI focused on skill performance, with research demonstrating ETI success rates of greater than 90% (Jacobs et al. 1983; Stewart et al. 1984).

Since the turn of the century, the performance of pre-hospital ETI by paramedics has come under increasing scrutiny. Researchers have generally found either equivocal or unfavourable outcomes associated with pre-hospital ETI by paramedics (Wang and Yealy, 2006). One possible explanation for these outcomes is the varying rates of adverse events that have been identified as being associated with paramedic pre-hospital ETI. The most serious of these adverse events is an unrecognised oesophageal intubation. The incidence of unrecognised oesophageal intubations by paramedics performing ETI in the pre-hospital setting has been reported to vary from 0–17% (Jacobs et al. 1983; Stewart et al. 1984; Pointer, 1988; Cobas et al. 2009). Intubation is an infrequently performed pre-hospital procedure and is most commonly performed for patients in cardiac arrest (Bendall et al. 2010).

Subscribe to get full access to the Journal of Paramedic Practice

Thank you for visiting the Journal of Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

  • CPD Focus

  • Develop your career

  • Stay informed

Register
Or continue by

Signing in with your registered email address

Emergency Medical Services
Endotracheal intubation
Oesophageal
Paramedic
Pre-hospital