{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T12:23:33Z","timestamp":1777379013071,"version":"3.51.4"},"reference-count":18,"publisher":"SAGE Publications","issue":"5","license":[{"start":{"date-parts":[[2024,8,31]],"date-time":"2024-08-31T00:00:00Z","timestamp":1725062400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Anaesth Intensive Care"],"published-print":{"date-parts":[[2024,9]]},"abstract":"<jats:p>Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.<\/jats:p>","DOI":"10.1177\/0310057x241244809","type":"journal-article","created":{"date-parts":[[2024,8,31]],"date-time":"2024-08-31T16:54:26Z","timestamp":1725123266000},"page":"302-313","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Oesophageal intubations in anaesthetic practice across Australia and New Zealand: A webAIRS analysis of 109 incidents"],"prefix":"10.1177","volume":"52","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8804-4168","authenticated-orcid":false,"given":"Yasmin","family":"Endlich","sequence":"first","affiliation":[{"name":"The University of Adelaide"},{"name":"School of Nursing, The University of Adelaide, Adelaide, Australia"},{"name":"Royal Adelaide Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas P","family":"Fox","sequence":"additional","affiliation":[{"name":"Royal Adelaide Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martin D","family":"Culwick","sequence":"additional","affiliation":[{"name":"Australian and New Zealand Tripartite Anaesthesia Data Committee, Melbourne, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher J","family":"Acott","sequence":"additional","affiliation":[{"name":"Royal Adelaide Hospital"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2024,8,31]]},"reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2021.1727"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aer059"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15817"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.aat.2014.06.001"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000001795"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X9302100519"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X221082664"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X1704500105"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X211060846"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1159\/000381252"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2016-0069"},{"key":"e_1_3_4_13_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.14359"},{"key":"e_1_3_4_14_2","article-title":"Airway management in neonatal intensive care units: the PIC-NIC survey","volume":"15","author":"Foy KE","year":"2019","unstructured":"Foy KE, Cook TM, Marden B, et\u00a0al. Airway management in neonatal intensive care units: the PIC-NIC survey. Infant 2019; 15. doi:10.1111\/anae.14359","journal-title":"Infant"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15894"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aer387"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2301601"},{"key":"e_1_3_4_18_2","first-page":"CD011136","article-title":"Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation","volume":"4","author":"Hansel J","year":"2022","unstructured":"Hansel J, Rogers AM, Lewis SR, et\u00a0al. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev 2022; 4: CD011136. doi:10.1002\/14651858.CD011136.pub3","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_4_19_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15492"}],"container-title":["Anaesthesia and Intensive Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0310057X241244809","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/0310057X241244809","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0310057X241244809","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:12:56Z","timestamp":1777367576000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/0310057X241244809"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,31]]},"references-count":18,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2024,9]]}},"alternative-id":["10.1177\/0310057X241244809"],"URL":"https:\/\/doi.org\/10.1177\/0310057x241244809","relation":{},"ISSN":["0310-057X","1448-0271"],"issn-type":[{"value":"0310-057X","type":"print"},{"value":"1448-0271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,8,31]]}}}