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(Circulation. 2000;102:I-380.)
© 2000 American Heart Association, Inc.

Editorials

Guidelines Based on the Principle "First, Do No Harm"

New Guidelines on Tracheal Tube Confirmation and Prevention of Dislodgment

Richard O. Cummins, MD; Mary Fran Hazinski, RN, MSN

In 1992 ECC experts thought the "gold standard" to confirm correct tracheal tube placement was the multiple, time-honored physical examination criteria:

• See the tube passing through the cords.
  
• Hear proper sounds when checking 5-point auscultation.
  
• See the chest expand with each ventilation.
  
• Note improvement in the level of oxygen saturation.
  
• See vapor condense in the tube with ventilations.
  

The experts and clinicians working on recommendations in 1992 rejected several proposals to add secondary confirmation techniques to the resuscitation guidelines. They did not recommend qualitative single-use devices that measured expired CO₂, largely because of expense. They did not accept the inexpensive esophageal detector device (EDD), in large part because the evidence revealed that errors still occurred with them. Continuous quantitative expired CO₂ measurements as a method to detect tube dislodgment were not even mentioned 8 years ago.

The original goals of secondary confirmation techniques were to

• Always identify and remove all esophageal intubations (100% sensitivity to failed intubations)
  
• Never remove a tracheal tube that is in the trachea (100% specificity to successful intubations).
  

In 1992 no secondary detection technique performed at this level, and none do now (2000). The evidence the experts used to support the decision to not recommend secondary confirmation devices was their strong confidence in a flawed assumption: the hallowed confirmation by physical examination criteria simply could not be improved (Level 8 evidence). In addition, no one asked the question, Does discovery of a tracheal tube in the esophagus in the Accident and Emergency Department or the . . . [Full Text of this Article]

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