The ‘No Trace=Wrong Place’ campaign

Editor

Thank you for the opportunity to reply to the letter by Jafferji and colleagues¹ on confirmation bias in oesophageal intubation. This letter draws attention to the ‘No Trace=Wrong Place’ campaign launched recently by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS). This safety campaign, aimed at all who manage patient airways, focuses on the importance of capnography in confirming tracheal intubation in all clinical settings, including during cardiac arrest. It has not been previously described in the British Journal of Anaesthesia, but the journal's influence and international reach have the potential to enhance dissemination of this safety message.

Jafferji and colleagues¹ described two patients who died in the UK as a result of unrecognised oesophageal intubation in 2016. Both incidents were described in the non-medical press,2, 3 and both are the subject of open-access coronial reports.4, 5 Both occurred in hospitalised patients during elective anaesthesia. In both cases, intubation was performed urgently when airway problems occurred, and in both cases, capnography was used. In both cases, cardiac arrest supervened. The flat capnograph present after attempted intubation was incorrectly deemed to be caused by the low or absent cardiac output during cardiac arrest. Both patients had tracheal tubes correctly placed after a significant delay, and both patients died as a result of hypoxic–ischaemic brain injury.

As a consequence of these cases and in response to coronial processes aimed at preventing future deaths, the RCoA and the DAS combined to produce an educational video reminding all who manage airways that a sustained capnograph trace is only present after successful tracheal intubation.⁶ If it is not present, the assumption should be that the intended tracheal tube is in the oesophagus, and immediate efforts should be made to identify and correct tube placement. This will nearly always involve removal of the tube and reintubation. There are several other technical possibilities for a flat capnograph but in the immediate aftermath of an attempted intubation, oesophageal intubation must first be excluded. Importantly, a capnograph trace, albeit attenuated, will be present even in the presence of cardiac arrest, with or without cardiopulmonary resuscitation.7, 8 Exhaled carbon dioxide remains detectable long after the onset of cardiac arrest, and its absence should never be attributed to the arrested state.

NHS Improvement had defined failed intubation that is not detected because of lack of capnography or its misinterpretation as a Never Event.⁹ This has been suspended whilst the wording is modified, but it is expected to be relaunched in the near future. One of the reasons that the Never Event was suspended was to enable discussion about whether to apply a lower age or weight limit to the Never Event. The feasibility, utility, and value of capnography in small babies have been hotly debated recently,10, 11, 12, 13 and there is currently an opportunity to appraise the evidence and make changes to practice. The need for detection of correct tracheal tube placement or dislodgement is as vital in small babies as it is in adults, as another recent neonatal death sadly illustrates.¹⁴

To detect a capnograph trace after intubation, one must be using capnography. The ‘No Trace=Wrong Place’ campaign and the Never Event publication reinforce other directives from several organisations that capnography should be used wherever tracheal intubation is undertaken, or patients are dependent on a tracheal tube and artificial ventilation. After the 4th National Audit Project of the RCoA and DAS, this was prominently emphasised in the UK¹⁵; the RCoA President wrote to all NHS Trust Chief Executives about it; and in the past decade, the use of capnography has dramatically increased in adult and paediatric practice.¹⁶ Recent evidence suggests that its use in perinatal and neonatal intensive care practice may be limited.¹⁰ Uptake may also be lower outside the UK, so to prevent similar events to those described previously, it is beholden on those who manage airways, clinical managers, administrators, and regulatory bodies to ensure that capnography is available and used during all attempts at tracheal intubation (organisational preparedness), and that those using it are educated to use and interpret it (personal preparedness).

These actions can prevent future avoidable patient harm and death, and also the secondary consequences for patients, their families, and those involved in their clinical care. We would support the routine use of verbalisation to ‘facilitate the activation of cognitive control processing’, although in the light of the ‘No Trace=Wrong Place’ campaign, we suggest that the words ‘good trace: right place’ might be pithier than ‘presence of a satisfactory capnography waveform trace’.

Declarations of interest

The department of TMC has received various pieces of anaesthetic airway equipment free or at cost for research or evaluation. He has no personal conflicts of interest. He is an Associate Editor of the British Journal of Anaesthesia. DKW has received funding from Medtronic for travel and associated costs in connection with the Global Capnography Project study in Malawi, and also lecture fees, all donated to Lifebox. The remaining authors declare that they have no conflicts of interest.