Portal de Periódicos da CAPES

Serious Hazards of Tracheal Intubation

1984; Elsevier BV; Volume: 86; Issue: 5 Linguagem: Inglês

10.1378/chest.86.5.802b

1931-3543

Bradley E. Smith,

Foreign Body Medical Cases

To the Editor: I have read with genuine admiration the report by Stewart et al. (Chest 1984; 85:341-45) describing the results of field endotracheal intubation by paramedical persons. I would like to suggest that the conclusions offered by the authors are in direct opposition to their own observed facts. They observed a 9.5 percent complication rate in 779 attempted intubations, including three with unrecognized esophageal placement of the endotracheal tube. Unrecognized esophageal placement of the endotracheal tube can be correlated with inevitable iatrogenic death in the comatose patient requiring respiratory assistance. Therefore, this incidence of presumably fatal complications of the procedure can only be justified if no alternative procedure exists which yields a smaller death rate. As correctly pointed out by the authors, available information concerning the esophageal obturator airway does not present sufficient hard data for a direct comparison. However, it should be borne in mind that these 130 paramedics were trained in what appears to be an ideal program. This 9.5 percent incidence of complications was produced by an exceedingly well trained group of paramedics. Rarely are such exemplary training opportunities for paramedics available. In addition, the conditions required for admission to study (complete flaccid coma) were ideal for tracheal intubation. An even higher complication rate would be expected in the more common circumstances of semi-coma and partial retention of muscle tone. In contrast, a quick search of the records in this university department of anesthesiology reveals no unrecognized esophageal intubations in the past 60,000 operating theater intubations (a period of about 12 years). Almost all of our intubations were carried out under paralysis and in the state of anesthesia which is very similar to complete coma and muscle paralysis as existed in this study by anesthesiology physicians in training and certified registered nurseanesthetists. I suggest that the data presented in this excellent study demonstrate that the serious complication rate after endotracheal intubation carried out by paramedical personnel, even after ideal training and under conditions stipulated to be perfect, is unacceptable if a reasonable alternative exists. Unfortunately, in my rather extensive experience in training paramedical personnel in this procedure, I find that too many seem to quickly assume unjustifiable pride in their new-found license to intubate the trachea and remain apparently ignorant of the very real possibility of serious and/or fatal complications from unnecessary endotracheal intubation. In our own institution, complications by non-anesthesia personnel have included hypopharyngeal tears, tracheal perforation, ruptured stomach, and mediastinitis, as well as cardiac arrest due to unduly prolonged attempts to intubate during apnea.