In the first part of this two-part article, we reviewed the tools and technology available to help ensure proper endotracheal tube placement through the detection and evaluation of end-tidal carbon dioxide (EtCO2).

The key takeaway from part one is that we need to understand, use and trust the equipment available and the information we are given. Each time; every time; all the time. When we lose track of that key principle, bad things happen.

As healthcare professionals, whether we work outside of hospitals, inside hospitals or between hospitals, our experience often leads us beyond direct patient care. For some, that means focusing on management responsibilities. For others, it leads to rewarding career paths in education and training. And for a few, opportunities arise to bridge professional interests and engage in the challenging work of providing expertise in medical-legal situations.

Among the more common medical-legal situations for which expert witnesses are needed are cases where airway management (or the lack thereof) has led to significant negative outcomes. As expert witnesses, we may work for the plaintiff team (representing the person harmed) or the defense team (representing the medical professionals and organizations being sued).

Avoidable or Correctable?

When dealing with airway-related medical malpractice suits, one of the first questions that must be asked is simply, was the situation avoidable or correctable? We all know that mistakes happen. (After all, we’re all human.) But was the training and preparation adequate for the level of responsibility? Were all precautions taken? Was the appropriate level of monitoring (e.g., human and mechanical) applied? Was the need for corrective action recognized and taken?

Unfortunately, in many cases, the harm was preventable (as would be the subsequent lawsuit). And avoiding that harm by preventing that disastrous outcome is actually quite simple. If people used the tools available and trusted their findings, catastrophic results could have been avoided.

An endotracheal tube, whether starting in the nose, mouth or neck, ends up in one of two places: the esophagus or the trachea. What makes matters more challenging is that where an endotracheal tube ends up initially may not be where it remains, especially through transports and transfers.

And when good airways go bad and the situation ends up in court, the root issues tend to revolve around one of two situations: 1) not using the available tools; or 2) not trusting the technology.

This usually means that the individual or team responsible for securing and maintaining the patient’s airway didn’t use an EtCO2 device, or they didn’t believe the findings.

In the cases where the appropriate tools weren’t used, this is simply unacceptable, both in practice and in court. For many years, in countries around the world, verification of tracheal tube placement (oral, nasal or cric) with EtCO2 has been the standard of care. This applies whether the location is a hospital procedure or operating room, during an inter- or intra-facility transfer, or on prehospital calls.

And this applies not only to adults, but to children and babies as well. Failure to follow the standard of care jeopardizes patient safety and professional careers.

The other major category of airway management mishaps involve situations where the CO2 detection devices were used, but the results weren’t trusted. Although no piece of technology is absolutely accurate 100% of the time, the failure rate of EtCO2 devices is remarkably low, especially when we understand the relative limitations discussed in part one of this article.

Use Your Tools

Case 1: A transport team was called for a premature infant in respiratory distress. Shortly after arrival, the team orally intubated the baby, but the baby continued to deteriorate. As just about everything bad that happens with babies starts with a respiratory problem, the deteriorating condition shouldn’t have continued once the endotracheal tube was placed.

A chest X-ray was done, and documentation of breath sounds, skin color, etc., was made in the chart (after the transport, of course). However, there was no documentation of the use of any sort of EtCO2 detection device.

It was determined that the transport team had colorimetric devices available to them and even had capnography available at the bedside. The nursery also had colorimetric devices available on their crash cart. The story was further complicated when the radiologist called the nursery 30 minutes later to report that the endotracheal tube was in the esophagus.

That’s a report no one ever wants to hear. The baby continued to deteriorate, and despite extensive resuscitation measures, expired in the nursery. What was the core issue? Tube placement wasn’t verified immediately after intubation. The team didn’t use the tools available.

Case 2: An ALS EMS crew was caring for a critically ill multi-trauma patient. They elected to perform a rapid sequence intubation (RSI) on the scene. Documentation of breath sounds, vitals, skin color, etc. was made in the chart. However, what was not documented? EtCO2. The patient continued to deteriorate in route and shortly after arrival in the ED, was found to be in full arrest.

The emergency physician performed video laryngoscopy to confirm the endotracheal tube placement and found the tube to be in the esophagus. It was discovered that the ALS crew had colorimetric devices available in their jump bag, but apparently didn’t use an available device to verify proper initial and ongoing placement of the endotracheal tube. What was the core issue? Not using the tools.

Case 3: While on the scene of an EMS incident, a flight team performed a RSI on a critically ill, head injured patient. Immediately after intubation, the tube position was verified not only by breath sounds, skin color and vital signs, but also with a colorimetric device.

That’s the good news. The patient was then manually bagged as the team made their way across a field en route to the awaiting aircraft. Upon securing the patient in the aircraft, the crew documented breath sounds, skin color, and vital signs, and removed the EMS EtCO2 detector. Shortly after liftoff, the patient deteriorated into traumatic arrest.

The crew, per their protocols, elected to extubate and reintubate in flight. Upon arrival to the trauma center, the new endotracheal tube was confirmed to be in correct position. Unfortunately, the patient expired despite extensive resuscitation efforts.

We know that endotracheal tube verification—and documentation—by way of EtCO2 detection is the standard of care not only immediately after intubation, but after any major move.

Those moves might be as unusual and complex as going across a field, as involved as transferring and securing a patient into a helicopter or other transport vehicle, or as common and basic as transferring a patient from an EMS stretcher to hospital stretcher.

Most colorimetric devices are identified as being reliable for between two and 24 hours of continuous use, so the answer to the question of why the crew removed the EtCO2 detector upon arrival to the aircraft is unknown; but this question definitely came into play as the case progressed.

Upon further review, it was found that the crew not only had the EtCO2 detector that was used as they moved across the field, but also additional replacement colorimetric devices available in their flight jump bag.

So, what was the core issue? Not using the tools with the consistency expected.

Trust the Technology

Case 1: A team arrived at a community hospital ED to transport an intubated young child with pneumonia to a facility with a pediatric ICU. In the ED, the tube position was verified not only by breath sounds, skin color and vital signs, but also with a colorimetric device.

However, after loading the patient into the ambulance that was to drive to the helipad, the patient began to quickly deteriorate.

It was documented that the colorimetric device was no longer changing from purple to yellow, and at that point remained purple with bagging. Shortly thereafter, the patient went into full arrest.

The team then administered epinephrine, began CPR, followed PALS protocols, and continued bagging through the endotracheal tube. Since the patient clearly wasn’t stable enough for transport, the transport team decided to return to the hospital ED.

Using direct visualization, the emergency department physician determined that the tube was in the esophagus and immediately replaced the endotracheal tube.

After several minutes, spontaneous circulation was obtained, but the child sustained significant hypoxic brain damage. What was the core issue? Not trusting the technology that indicated that the was no longer in place.

Case 2: A team was flying a seriously ill, intubated child, to a pediatric ICU. The team had a capnograph in use. Mid-flight, the child began to deteriorate and the capnography waveform became flat. The child then quickly deteriorated into full arrest.

For several minutes, the medical team continued to bag through the endotracheal tube, which was displaying a flat capnography reading. The team administered epinephrine, began CPR, and followed PALS protocols, but made no changes in terms of their airway management.

Eventually the flight crew notified the pilots that they need to land as soon as possible so the child could be reintubated.

After landing in a field, the team quickly replaced the endotracheal tube and, shortly thereafter, spontaneous circulation was obtained. But after being in full arrest for over 15 minutes, the child sustained significant hypoxic brain damage. What was the core issue? Not trusting the technology and reacting in a timely fashion.

Case 3: An adult patient suffered head and neck injuries as a result of a fall. There was progressive neck swelling and concerns about the patient’s ability to maintain a patent airway, so intubation was attempted on scene by an ALS ground crew and flight crew.

Attempts at oral intubation were unsuccessful and a surgical cricothyroidotomy was performed prior to flight. A 6.5 mm endotracheal tube was placed in the patient. Immediately after placement, documentation of breath sounds, skin color and vital signs were documented. The capnography waveform, however, was flat. The team then changed the EtCO2 adapter, but the waveform remained flat.

As the patient continued to rapidly deteriorate, the team then tried another capnography monitor.

That second capnography monitor still displayed the flat waveform. Finally, the team replaced the second monitor’s EtCO2 adapter, but the waveform continued to show a flat line. As the patient had now progressed into full arrest, the flight team opted to fly the patient to the nearest hospital.

Despite aggressive resuscitation measures, the patient was pronounced dead upon arrival to the ED. Autopsy findings revealed that the endotracheal tube placed via the surgical cricothyroidotomy ended up in the esophagus, and not in the trachea.

The cause of death was listed as esophageal intubation. What was the core issue? Not trusting the technology—multiple times.


Although practice may not make perfect, it certainly can make proficiency. And when it comes to airway management, for every tube, every time, every age, everywhere … capnographic (or at least capnometric or colorimetric) verification of proper initial and ongoing placement is the standard of care.

If being the subject of a serious medical malpractice lawsuit is among the things you strive to avoid, get in habit of using your tools and trusting the technology.