Misplaced Tubes

Misplaced Tubes

The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.


Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. Annals of Emergency Medicine, May 2005, pgs 497-503l

If there ever was an argument for requiring continuous ETCO2 monitoring on all intubations, this is it. Over a ten month period, in 11 counties in Florida there were 153 intubations. 93 (61%) used continuous ETCO2 Monitoring. 60 (39%) did not. Upon arrival at the Emergency department there were 14 (9%) unrecognized misplaced intubations. There were 0 (0%) misplaced tubes in the group that used continuous ETCO2 monitoring. There were 14 (23%) in unmonitored group.

The authors wrote: “The unobserved unrecognized misplaced intubation risk difference is compelling. This study demonstrates that it is possible to attain a zero unrecognized misplaced intubation rate.”

Four years earlier, another study was done in Florida that showed during an 8 month period out of 108 “intubated” patients brought to a large Florida ED, there were 27 misplaced tubes (27%) on arrival at ED. 18 were in the esophagus, 9 in hypopharanx. 17 of 18 esophageal intubations had an absence of expired CO2, the one with CO2 was nasally intubated and breathing their own. 4 of 9 hyphopharengal intubations had an absence of expired CO2.
- Katz SH, Falk JL, Misplaced endotracheal tubes by paramedics in an urban emergency medical services system, Annals of Emergency Medicine, January 2001

The authors wrote: “The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occuring in other communities...Functionally, whether the tubes were misplaced initially or dislodged en route to the hospital makes little difference to the patient....Despite written protocols requiring the out-of-hospital use of ETCO2 devices in our community, we...found their use to be sporadic... We believe that routine use of this technique, both at the time of intubation and as an ongoing monitor during transport, could potentially eliminate the problem of unrecognized misplaced ETT placement....”

Bottom Line: Intubated patients should all have continuous ETCO2 monitoring.