Anesthesia Incident Reporting System (AIRS) Case 2024-01: The Lingering Perils of Esophageal Intubation and Patient Harm

A patient suffered from a cervical esophageal perforation caused by accidental esophageal intubation. The patient underwent an elective procedure and was intubated by a doctor who was still in training. In the process, the patient developed mediastinitis, a retropharyngeal abscess, and a pleural space abscess. Multiple surgical interventions were required and led to a significantly prolonged hospital stay. During the course, the patient suffered multiple complications, including deep vein thrombosis, gastrointestinal bleeding, respiratory failure, and septic shock. The patient was discharged initially on tube feeds but tolerated a normal diet at the writing of the incident report.

However, even when immediately noticed, esophageal intubation has been linked to hypoxemia, pulmonary aspiration, cardiac arrest, and significant damage to the esophagus (Acta Anaesthesiol Taiwan 2014;52:143-5; Eur J Cardiothorac Surg 2001;20:7-10). Often, the patient must undergo extensive surgical repair requiring intensive medical care, leading to a prolonged recovery and rehabilitation period, similar to what has been described in this report. Therefore, all efforts must be warranted to avoid esophageal intubations in clinical practice (Acta Anaesthesiol Taiwan 2014;52:143-5; Eur J Cardiothorac Surg 2001;20:7-10).

Esophageal intubations have been described across all patient populations in both straightforward routine situations and challenging intubations, whether undertaken by experienced or inexperienced clinicians (Anaesth Intensive Care 1993;21:608-10). Recently developed consensus guidelines from the Project for Universal Management of Airways (PUMA) (Anaesthesia 2022;77:1395-415) aim to provide a strategy for preventing the occurrence of unrecognized esophageal intubation. Several human factors strategies to avoid bias and assessments to immediately recognize esophageal intubations are described in the document. However, the guidelines also provide good insight into the causes of esophageal intubations and recommendations and strategies to prevent esophageal intubations from occurring.

The guidelines list a range of possible reasons for esophageal intubation. Examples are the misidentification of the larynx, which may be caused by limited operator expertise or supervision, a compromised view, airway pathology, equipment issues, or a combination of various factors. Commonly described delivery issues include the endotracheal tube not passing into the trachea, the introducer not passing into the trachea, or displacement of the tube, the introducer, or bronchoscope. Equally, movement after successful tracheal intubation due to subsequent airway instrumentations, patient coughing or gagging, changes in position, or performance of chest compressions have been mentioned (Anaesthesia 2022;77:1395-415).

The authors also provide valuable recommendations to prevent esophageal intubations from happening and highly recommend the routine use of videolaryngoscopy whenever feasible. Benefits include the improved glottic view by the operator but also by the team members, which allows them to confirm or question correct tube placement (Anaesthesia 2022;77:1395-415).

Another recommendation is the deliberate, sequential exposure of the anatomy during laryngoscopy, combined with verbalizing the view and describing the anatomical structures at each step. Verbalization of actions has been described and is used in other safety-critical industries and is recognized for the ability to decrease the number of perceptual errors (Journal of Patient Safety & Quality Improvement 2017;5:577-83; Safety at the Sharp End: A Guide to Non-Technical Skills. 2008).

Multiple potential sequelae of intubation-related iatrogenic esophageal injury have been described in the literature, including retropharyngeal abscesses, mediastinal abscesses, subcutaneous emphysema, sepsis, respiratory distress symptoms, pleural effusion, and laryngeal nerve paralysis after surgical repairs (Acta Anaesthesiol Taiwan 2014;52:143-5; Eur J Cardiothorac Surg 2001;20:7-10). Therefore, it is important to use strategies to avoid intubation-related iatrogenic esophageal injury, including using videolaryngoscopes to increase tracheal intubation success, ensuring the stylet tip does not protrude beyond the edge of the endotracheal tube, and gentle, skillful use of bougies.

If an esophageal tear occurs, it is commonly located in either the upper third of the esophagus below the opening on the posterior wall in the piriform sinus or in the inferior esophagus just above the esophagogastric junction (Eur J Cardiothorac Surg 2001;20:7-10). Positive pressure ventilation using a facemask may induce subcutaneous emphysema and, when appearing at the time of airway instrumentation, allows for an early diagnosis (Acta Anaesthesiol Taiwan 2014;52:143-5; Eur J Cardiothorac Surg 2001;20:7-10). Of note, iatrogenic esophageal injuries are often only diagnosed two to three days post-surgery when feeding attempts are started (Eur J Cardiothorac Surg 2001;20:7-10). The most common first symptoms are pain when swallowing and reluctance for oral intake.

The combination of dysphagia and subcutaneous emphysema is a strong indicator for diagnosis. A bronchoscopy will rule out a tracheobronchial rupture, and a CT scan will identify the esophageal injury. In unconscious ventilated patients, sepsis may be the only clinical sign, and a high level of suspicion is required. Detailed documentation of intubation attempts and accidental esophageal intubation might support early diagnosis.

Post-intubation, esophageal perforation may progress to a life-threatening iatrogenic complication if not diagnosed and treated early. These events are considered surgical emergencies and require urgent attention. Surgical treatment usually involves the drainage of the abscesses and repair of the esophageal tear and, depending on the extent of the injury, may require a mini-laparotomy to create a feeding jejunostomy and a thoracotomy to relieve the pleural effusion (Acta Anaesthesiol Taiwan 2014;52:143-5; Eur J Cardiothorac Surg 2001;20:7-10).

The reported case highlights that preventing this complication begins with avoiding esophageal intubation in general, using techniques to reduce the risk of injury, and ensuring rapid diagnosis leading to early surgical repair.