A Potential Method for Safe Recovery from Recognized Inadvertent Esophageal Intubation

How to proceed following inadvertent esophageal intubation and what to do with the misplaced endotracheal tube is controversial and not specifically addressed in the difficult airway algorithm from the American Society of Anesthesiologists. Here we describe a simple and effective strategy to manually ventilate the patient with an air cushioned face mask while leaving the endotracheal tube in the esophagus to provide a conduit for stomach content suction until definitive endotracheal intubation. We describe clinical circumstances in which we used this method successfully. Whether to leave the endotracheal tube in the esophagus or what to do with it should be specifically addressed in difficult airway algorithms.


INTRODUCTION
How to proceed following inadvertent esophageal intubation and what to do with the misplaced endotracheal tube is controversial and not specifically addressed in the difficult airway algorithm from the American Society of Anesthesiologists [1,2].Following recognition of an esophageal intubation, it is often routine and instinctive practice to remove the endotracheal tube prior to manual bag-mask ventilation or before proceeding with securing the airway.During this time however, the patient is at risk for aspiration as well as hypoxemia.In a review of morbidity associated with accidental esophageal intubation, Mort reports rates of regurgitation (24.7%), aspiration (12.8%) severe hypoxemia (25%) [3].Other injuries such as esophageal tear, gastric rupture, or entry of a foreign body are more unusual complications after a difficult tracheal intubation and inadvertent esophageal intubation, but may occur even when recognized immediately [4][5][6].
Subsequent definitive airway management may also be difficult and prolonged delay may lead to hypoxia, arrhythmias and cardiac arrest.A simple and effective strategy was developed to manually ventilate the patient with an air cushioned face mask while leaving the endotracheal tube in the *Address correspondence to this author at the Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, K7L 2V7 Canada; Tel: (613) 548-7827; Fax: (613) 548-1375; E-mail: burjorjj@kgh.kari.netesophagus to provide a conduit for stomach content suction prior to definitive endotracheal intubation.The esophageal endotracheal tube was subsequently removed and replaced by a standard nasogastric tube.Here we briefly describe our method for safe recovery from inadvertent esophageal intubation and describe clinical circumstances in which it has been used successfully.

REPORT
Institutional Ethics Board approval was obtained to describe the following cases in which our method for recovery from inadvertent esophageal intubation was used.

Method Description
Following recognition of inadvertent esophageal intubation, the standard 15 mm endotracheal tube connector is replaced with, either a standard nasogastric tube doubletapered connector or a Medi-Vac® 5 in 1 straight polypropylene tubing connector and this is hooked up to suction tubing (Fig. 1) to evacuate stomach contents.Next a transparent air cushioned facemask (Westmed®) is applied while bending the endotracheal tube down the left side of the face and manual bag-mask ventilation started (Fig. 2).After adequate oxygenation, the airway can be secured with other options with minimal aspiration risk.The method described here makes it easy to maintain an adequate seal and provide patient ventilation with the facemask, while allowing for continuous suction of stomach contents.Following success-ful endotracheal intubation, the esophageal tube is removed and replaced with a nasogastric tube.

Case Descriptions
We have used this technique successfully in morbidly obese patients with full stomachs and in a difficult airway case involving a cervical spinal fracture and bowel obstruction.These patients were all at high risk of aspiration.Esophageal intubation was immediately recognized by standard methods including absence of end tidal carbon dioxide on capnography and the method described above was utilized.Successful suctioning of stomach contents via the esophageal endotracheal tube avoided any potential pulmonary aspiration.In the latter case, ventilation was easily managed avoiding hypoxemia and the airway secured with the aid of a GlideScope®.Performance of blind nasal intubation following inadvertent esophageal intubation was also facilitated by using this technique since the presence of the esophageal endotracheal tube provided anterior direction to the nasal tube.

Figs. (1).
Following inadvertent esophageal intubation, the endotracheal tube connector is replaced with the standard nasogastric tube double tapered connector or a Medi-Vac® 5 in 1 straight polypropylene tubing connector (Fig. 1) and this is hooked up to standard suction tubing to evacuate stomach contents.

Figs. (2).
A transparent air-cushioned face mask (Westmed®) is applied while bending the endotracheal tube down the left side of the face and manual oxygen-bag-mask ventilation started (Fig. 2).

DISCUSSION
Many articles discuss methods of recognizing inadvertent esophageal intubation but offer little guidance on how to proceed when it occurs.Although simple, the method described here would allow effective ventilation in many patients while still providing a conduit for the suction of gastric contents.It may be a useful and inexpensive bridging technique in difficult airway management and may help to avoid aspiration and hypoxemia.The option to perform a blind nasal intubation is also made more feasible since intubation of the trachea is easier with esophageal occlusion as it provides anterior direction to the endotracheal tube.Whether to leave the endotracheal tube in the esophagus or remove it should be specifically addressed in difficult airway management algorithms.