Sakles John C, Ross Christopher, Kovacs George
Department of Emergency Medicine University of Arizona College of Medicine Tucson Arizona USA.
Department of Emergency Medicine Mercy Health Javon Bea Hospital Rockford Illinois USA.
J Am Coll Emerg Physicians Open. 2023 Apr 29;4(3):e12951. doi: 10.1002/emp2.12951. eCollection 2023 Jun.
Tracheal intubation is a commonly performed procedure on critically ill patients in the emergency department. It is associated with many serious complications, one of the most dangerous being unrecognized esophageal intubation, which can result in anoxic brain injury, cardiac arrest, or death. It is the responsibility of the emergency physician to do everything possible to avoid this devastating complication. Preventing unrecognized esophageal intubation requires a two-pronged approach. First, the inadvertent placement of intended tracheal tubes into the esophagus must be reduced as much as is humanly possible. This can be achieved with the routine use of video laryngoscopes for emergency department intubations. Numerous studies have demonstrated that use of video laryngoscopes can significantly reduce the occurrence of esophageal intubation, presumably by providing an improved view of the larynx. Second, if an esophageal intubation inadvertently occurs, it must be rapidly identified and appropriately addressed. The cornerstone of rapid identification is the use of continuous waveform capnography to detect exhaled carbon dioxide. Capnography has been shown to be the most accurate method to determine tube placement after intubation. Standard clinical examinations, for example, auscultation of breath sounds, visualization of chest excursion, and observation of condensation in the tube, have all been demonstrated in studies to be unreliable and thus should not be used to esophageal intubation. Recently, the Project for Universal Management of Airways, an international collaborative of airway experts from anesthesiology, critical care and emergency medicine, published evidence-based guidelines to specifically address the issue of preventing unrecognized esophageal intubation. These guidelines, which have received endorsement from several prominent airway societies, including the Society for Airway Management, the Difficult Airway Society, and the European Airway Management Society, will be briefly discussed in this review.
气管插管是急诊科对危重症患者常用的操作。它会引发许多严重并发症，其中最危险的之一是未被识别的食管插管，这可能导致缺氧性脑损伤、心脏骤停或死亡。急诊医生有责任尽一切可能避免这种毁灭性的并发症。预防未被识别的食管插管需要采取双管齐下的方法。首先，必须尽可能减少将气管导管误插入食管的情况。这可以通过在急诊科插管时常规使用视频喉镜来实现。大量研究表明，使用视频喉镜可以显著减少食管插管的发生，大概是因为它能提供更好的喉部视野。其次，如果无意中发生了食管插管，必须迅速识别并妥善处理。快速识别的关键是使用连续波形二氧化碳描记法来检测呼出的二氧化碳。二氧化碳描记法已被证明是确定插管后导管位置最准确的方法。例如，标准的临床检查，如听诊呼吸音、观察胸部起伏以及观察导管内的冷凝情况，在研究中都已被证明不可靠，因此不应将其用于判断食管插管。最近，气道通用管理项目，一个由麻醉学、重症医学和急诊医学领域的气道专家组成的国际合作组织，发布了基于证据的指南，专门针对预防未被识别的食管插管问题。这些指南已得到包括气道管理协会、困难气道协会和欧洲气道管理协会在内的几个著名气道协会的认可，本文将对其进行简要讨论。
