Esophageal intubation with indirect clinical tests during emergency tracheal intubation: a report on patient morbidity.

STUDY
OBJECTIVE: To determine the consequences of esophageal intubation (EI) when using standard indirect clinical tests to detect endotracheal tube (ETT) placement in the emergency setting outside the operating room (OR).
DESIGN: An observationally based review of a quality improvement database for emergency intubation outside the OR.
SETTING: Seven hundred sixty-five-bed tertiary care, level I trauma center in central Connecticut. PATIENTS: Critically ill patients (n = 2377) experiencing cardiopulmonary, traumatic, septic, metabolic, or neurologic-based deterioration and requiring emergency airway management. Tracheal intubation of patients with cardiopulmonary resuscitation and chest compressions were excluded. MEASUREMENTS: A quality improvement emergency intubation database from 1990 to 2001 was reviewed to determine the incidence of EI and its associated complications (mild and severe hypoxemia, regurgitation, aspiration, hemodynamic alteration, cardiac dysrhythmias, and cardiac arrest) when ETT position is determined by standard indirect clinical tests without the benefit of ETT-verifying devices.
RESULTS: Patients who had EI, in contrast to those who did not, had significant rates of hypoxemia (64.7% vs 13.1%; P < .001) and severe hypoxemia (Spo2 < 70%) (25% vs 4.4%; P < .001). The rate of regurgitation (24.7% vs 2.4%) and aspiration (12.8% vs 0.8%) also differed significantly (P < .001). The overall incidence of bradycardia, typically hypoxia-driven, was more common (14-fold) after EI (21.3% vs 1.5%), as was new onset cardiac dysrhythmia (6-fold increase, 23.4% vs 4.1%) and cardiac arrest (14-fold increase, 10.2% vs 0.7%), all P < .001.
CONCLUSION: These data suggest that EI during emergency intubation, when detected by standard indirect clinical tests based on physical examination, contributes significantly to mild and severe hypoxemia, regurgitation, aspiration, bradycardia, cardiac dysrhythmias, and cardiac arrest. Pursuing methods to hasten the detection of EI in the emergency setting appear warranted.