Oesophageal intubation: An analysis of 2000 incident reports

R. Holland, R. K. Webb, W. B. Runciman

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There were 35 oesophageal intubations in the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). These reports confirm existing impressions that misplacement of the endotracheal tube can occur in trained as well as untrained hands, and that auscultation is an unreliable test. On the other hand, the value of capnography is emphasised, with no false positives in the 16 cases in which the instrument was used. There was one false negative. Over the 4 years of the AIMS study, reports have declined in frequency. It is possible that the early detection of oesophageal intubation by capnography has altered its status to the extent that anaesthetists no longer regard it as a 'critical' incident. It is highly recommended that the presence of the expected concentration of carbon dioxide in expired air be confirmed by capnography immediately after any endotracheal intubation.

Original languageEnglish
Pages (from-to)608-610
Number of pages3
JournalAnaesthesia and Intensive Care
Issue number5
Publication statusPublished or Issued - 1 Jan 1993
Externally publishedYes


  • Anaesthesia
  • Complications

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Anesthesiology and Pain Medicine

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