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MISPLACED
ENDOTRACHEAL TUBES A
COMMON PROBLEM
ORLANDO,
FLA—Endotracheal
tube misplacement by paramedics is more common than previously believed, suggests
a study of the emergency medical services (EMS) system in Orange County, Florida.[1]
Of the 108 intubated patients studied, 25% were found to have an improperly
placed endotracheal tube when they arrived at the emergency department.
“That
rate is alarmingly high,” said Jay L. Falk, MD, one of the study authors.
“The medical literature places the occurrence of misplaced endotracheal tubes
at around only 1% to 5%.” The high incidence in Orange County may
reflect a ubiquitous problem, suggested Dr. Falk, who is the Academic Chairman
of the Department of Emergency Medicine at Orlando Regional Medical Center in
Florida. “I have presented this study around the country, and its results
ring true with many colleagues,” he told PULMONARY
REVIEWS.
Patients intubated by Orange
County paramedics and admitted to the emergency department were eligible for the
study, which ran from May 1 to December 31, 1997. Each patient’s endotracheal
tube was assessed on arrival, starting with auscultation of the chest and epigastrium.
Epigastric sounds or vomiting from the tube were considered signs of obvious misplacement
in the esophagus. Those tubes were removed.
When misplacement was not
apparent, the tube was assessed with end-tidal carbon dioxide (ETCO2)
monitoring and direct laryngoscopy. A tube was considered correctly placed if
it passed between the vocal cords or if the patient had bilateral breath sounds
and a positive ETCO2 waveform and the tube was at an appropriate
depth.
All other tubes were categorized
as misplaced, either in the hypopharynx (if the tip of the tube was visible above
the vocal cords) or the esophagus. “Our study did not assess the intubation
skills of the paramedic,” stressed Dr. Falk. “It is certainly possible
that misplaced tubes were correctly inserted and then became misplaced by movement
on the way to the emergency department.”
Slightly more than half the
study subjects were medical patients, and the remainder were trauma patients requiring
cervical spine immobilization. The rate of tube misplacement was significantly
higher in the latter group (37% vs 14% in the medical patients).
Two thirds of the misplaced
tubes were in the esophagus and one third were in the hypopharynx. Esophageal
and hypopharyngeal placements were associated with mortality rates of 56%
and 33%, respectively. Tube misplacement was much more common in this study
than in the literature because intubation research is usually done by well-run
EMS systems that exercise tightly controlled oversight of paramedic training and
practice, speculated Dr. Falk. Good medical direction, quality assurance, and
regular intubation training for paramedics may markedly reduce tube misplacement
rates, he suggested.
Continuous ETCO2
monitoring from the time of intubation is also essential, Dr. Falk added. “Routine
use of these monitors to verify tube position has virtually eliminated tube misplacement
in some EMS systems,” he said. “But the monitors have yet to be embraced
by emergency medicine.”
—Deborah
L. O'Connor
Reference
1. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency
medical services system. Ann Emerg Med. 2001;37:32-37.
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