What is the criterion standard for confirmation of correct tube placement in rapid sequence intubation (RSI)?

Updated: Feb 28, 2019
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Answer

Accurate confirmation of correct placement of the tube in the trachea is essential. Direct visualization of the tube was previously the criterion standard for confirming placement; however, this method can be fraught with human error. The current criterion standard is end-tidal carbon dioxide detection, using either a calorimetric capnometer that changes color from purple to yellow with CO2 exposure or a quantitative capnometer that measures CO2 levels and can display a waveform. The yellow color change should occur rapidly within 1-2 breaths, and esophageal or supraglottic placement should be assumed if the color change is less rapid or does not occur at all. Important to note is that color change with a calorimetric capnometer can occur with esophageal placement and can be misleading. For this reason, a capnography with continuous waveforms is the preferred modality. Color change may not be reliable in cases of prolonged cardiac arrest. Clinical parameters such as pulse oximetry readings or tube condensation may be nonspecific and misleading. A canine study by Kelly and colleagues demonstrated tube condensation in up to 83% of esophageal intubations. [12]


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