Pitfalls of overreliance on capnography and disregard of visual evidence of tracheal tube placement: A pediatric case series

Background

Confirming the placement of an endotracheal tube in a pediatric patient is a critically important step in resuscitation, and no single method of confirmation has been proven to be completely reliable. Capnography has become the standard-of-care in confirming endotracheal tube placement in many institutions and guidelines. However, it has inherent limitations in critically ill patients.

Case report

Two pediatric patients presented with acute hypoxemic respiratory failure in the emergency department and both underwent endotracheal intubation with video laryngoscopy. Post-intubation capnography showed no evidence of end-tidal carbon dioxide production. The clinicians assumed a misplaced endotracheal tube for both patients despite multiple emergency physicians simultaneously visualizing the endotracheal tube being placed through the vocal cords on the video laryngoscopy monitor. Both patients subsequently underwent multiple repeated intubations for over 30 minutes without any change in capnography findings. In one case, the reason for the lack of capnography findings was incorrectly connected capnography tubing; for the other, a positive capnography finding was only visualized after surfactant administration allowed adequate ventilation.

Why should an emergency physician be aware of this?

Capnography, though a valuable tool, is not an infallible method of endotracheal tube placement confirmation. Sole reliance on one method of confirmation, particularly in light of other compelling evidence—eg, clear visualization of tube passage through the vocal cords by multiple experienced physicians—should be avoided.