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Lesson

Unrecognized Esophageal Intubation

12 min Airway & Breathing Skip to quiz

Objective: Treat a flat waveform as an esophageal tube until you prove otherwise. Pull the tube and oxygenate. Do not listen your way out of a flat trace.

Why this matters

An esophageal tube happens to experienced people on looks that seemed easy. It occurs in more than 1 in 18 emergency intubations of the critically ill. Waveform capnography is how you rule out the esophagus. Fog in the tube, chest rise, and listening are often wrong. A color-change detector can be wrong after carbon dioxide from the stomach. Crews then say it is just arrest, or it is just bronchospasm, and leave a tube in the stomach. No sustained waveform means the tube is in the wrong place.

Verbalize
  • I turn on the waveform before the look. End-tidal carbon dioxide is that trace. I confirm the monitor actually traces during preoxygenation.
  • I say “sustained waveform” or “flat trace” out loud. My partner agrees or challenges me.
  • Sustained means a repeating wave that rises on exhalation, holds or grows over several breaths, and is not a tiny blip from stomach gas or a carbonated drink.
  • If the trace is flat, I pull the tube and oxygenate. Fog in the tube is not confirmation.

Clinical sequence

  1. Pass the tube. Watch the waveform, not the fog in the tube. Your partner watches the screen.
  2. If there is no sustained exhaled carbon dioxide, treat the tube as esophageal until you prove it is not. Pull the tube and oxygenate with a bag or a supraglottic airway.
  3. Do not spend the falling sat on a five-point listen. Breath sounds do not rule out an esophageal tube. In a major review, mist in the tube was a false positive about 69% of the time. Breath sounds on both sides still miss the esophagus often enough to kill.
  4. After every move, vomit, or packaging, look at the waveform again. A good trace at the curb can be a flat line in the ambulance. Packaging, compressions, and children move tubes.

Teaching points

  • The default is to pull the tube and oxygenate. The only exception is an immediate look that visually reconfirms the trachea, preferably on video, with a plan to pull the tube if the waveform stays flat or the sat falls. Do not leave a flat-trace tube in place while you debate it.
  • Cardiac arrest and severe bronchospasm are the two stories people use to keep a bad tube. High-quality cardiopulmonary resuscitation (CPR) still produces carbon dioxide if the tube is in the trachea. A flat line is not just arrest. Do not call a flat waveform bronchospasm and leave the tube in.
  • “I saw it pass the cords” through blood, vomit, and movement is not confirmation. A color-change device used once is not continuous monitoring. Taking the tube out is not failure.

Common errors

  • Calling a flat waveform bronchospasm without pulling the tube.
  • Trusting “I saw it pass the cords” through blood, vomit, and movement.
  • Using a color-change device once and never looking again.
  • Leaving a tube in because taking it out feels like failure.

Practice

One-minute check

Partner: you passed a tube, the chest seems to rise, the sat was 99% from preoxygenation, and the capnograph is flat. Say the first sentence. Then they arrest. What is still the first problem?

Related: Waveform Capnography, Post-Intubation Care, Video Laryngoscopy in the Field.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. A new tube with a flat capnograph and “good” breath sounds should be treated as:
2. The default when you cannot get sustained exhaled CO₂ is:
3. Fog in the tube after intubation:
4. After you move an intubated patient for transport, you should:
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