Table 1.

Potential factors contributing to unrecognised oesophageal intubation. An expanded version of this table is available at https://www.UniversalAirway.org/puoi.

Occurrence of oesophageal intubation

Misidentification of larynx ■ Limited operator expertise/Inadequate supervision ■ Practitioner complacency ■ Compromised performance ■ Compromised laryngeal view ■ Distorted glottic anatomy ■ Glottic impersonation ■ Equipment issues

Delivery issue ■ Tube, introducer or bronchoscope not passed into trachea or displaced during railroading ■ Blind intubation via supraglottic airway

Movement after successful tracheal placement Withdrawal of bougie, stylet or flexible bronchoscope Subsequent airway instrumentation Patient coughing or moving Chest compressions Changes in patient position Paediatric patients Poorly secured tube

Failure to recognise oesophageal intubation *

CO 2 detection not available/used/functioning

Failure to confirm CO 2 detection

Spurious CO 2 detection ■ False‐positive CO2 detection using colorimetry ■ CO2 detection in association with oesophageal intubation

Misinterpretation of monitoring display: ■ Confusion of airway pressure waveform with capnography waveform

Failure to acknowledge the potential for absence of sustained exhaled CO 2 to indicate oesophageal intubation. ■ Cognitive biases ■ Knowledge deficits ■ Communication deficits

^*Many of these may be a consequence of, or aggravated by, stress and suboptimal teamwork.