A Two-Person Verbal Check to Confirm Tracheal Intubation: Evaluation of Practice Changes to Prevent Unrecognised Oesophageal Intubation
Background
Tracheal intubation is a critical procedure in anesthesia and intensive care. However, despite international campaigns emphasizing the use of capnography to confirm tracheal intubation, unrecognized esophageal intubation continues to result in patient deaths. Esophageal intubation is an avoidable and potentially fatal complication, especially in emergency situations, where intubators may rely on clinical signs (such as chest movement and auscultation of breath sounds) to confirm tube placement. However, these methods are unreliable and prone to confirmation bias. Additionally, hierarchical team structures may hinder other members from “speaking up” when potential issues are identified, further increasing patient risk.
To address this issue, international consensus guidelines recommend the use of a two-person verbal check to confirm tracheal intubation. This confirmation can be done through a one-step process (confirming sustained capnography waveforms) or a two-step process (confirming the passage of the tracheal tube through the vocal cords during videolaryngoscopy, followed by capnography confirmation). However, although this two-person confirmation method has been recommended in some clinical practices, its feasibility and acceptability have not been systematically evaluated.
Source of the Paper
This paper was authored by Thomas Cloke et al., with contributors from two hospitals in the UK: the Royal United Hospitals NHS Foundation Trust in Bath and Guy’s and St Thomas’ NHS Foundation Trust in London. The paper was published on October 19, 2024, in the British Journal of Anaesthesia, titled A two-person verbal check to confirm tracheal intubation: evaluation of practice changes to prevent unrecognised oesophageal intubation.
Research Process
Study Design
The study aimed to evaluate the feasibility and acceptability of introducing a two-person verbal check for tracheal intubation in two hospitals of different sizes and configurations. The research was conducted in four stages at the Royal United Hospital in Bath and Guy’s Hospital in London, from May 2022 to May 2023.
Stage 1: Initial Survey
Before introducing the two-person check, researchers collected the opinions of intubators and assistants on the feasibility and acceptability of the two-person check through anonymous online questionnaires. The survey included questions about the expected effects, potential benefits, and possible drawbacks of the two-person check.
Stage 2: Evaluation of the One-Step Two-Person Check
In both hospitals, researchers introduced the one-step two-person check, where both the intubator and assistant confirmed the presence of sustained capnography waveforms. After each intubation, intubators and assistants completed online questionnaires to evaluate the feasibility and effectiveness of this step.
Stage 3: Evaluation of the Two-Step Two-Person Check
Only at the Royal United Hospital in Bath was the two-step two-person check evaluated. This process involved confirming the passage of the tracheal tube through the vocal cords during videolaryngoscopy, followed by capnography confirmation. Researchers collected feedback from intubators and assistants through online questionnaires.
Stage 4: Exit Survey
After the study concluded, researchers conducted an exit survey of intubators and assistants at both hospitals to assess their overall perception of the two-person check and whether they planned to continue using this method in the future.
Key Findings
Initial Survey
In the initial survey, most intubators (116⁄149, 78%) and assistants (70⁄72, 97%) believed that the two-person check could reduce the risk of unrecognized esophageal intubation. Intubators felt that this method improved communication and teamwork (118⁄149, 79%), while assistants reported feeling more empowered to voice concerns when necessary (69⁄72, 96%), a flattening of the team hierarchy (53⁄72, 74%), and a greater sense of being valued as team members (64⁄72, 89%).
Evaluation of the One-Step Two-Person Check
In the one-step evaluation, intubators and assistants completed post-intubation questionnaires after 269 and 207 intubations, respectively. The results showed that 83% of intubators believed the two-person check made tracheal intubation confirmation more structured, 66% felt it made the process more thorough, and 70% reported an increased emphasis on technical methods (such as capnography and videolaryngoscopy) rather than relying on clinical signs.
Evaluation of the Two-Step Two-Person Check
In the two-step evaluation, intubators and assistants completed post-intubation questionnaires after 130 and 104 intubations, respectively. The results showed that 95% of intubators planned to continue using the two-person check in the future, and 91% believed it reduced the risk of unrecognized esophageal intubation. Among assistants, 97% expressed willingness to continue using the two-person check, and 93% reported understanding what to look for during videolaryngoscopy.
Exit Survey
In the exit survey, 89% of assistants reported that the two-person check made them feel more valued as team members, and 74% felt it helped flatten the team hierarchy. The majority of intubators (82%) and assistants (94%) planned to continue using the two-person check in the future.
Conclusion
The study demonstrated that the two-person verbal check for tracheal intubation is feasible and acceptable in both hospitals. Most participants believed this method could reduce the risk of unrecognized esophageal intubation and planned to continue using it. The two-person check not only improved the technical accuracy of confirmation but also enhanced team communication and collaboration, reducing barriers caused by hierarchical team structures.
Research Highlights
- Key Findings: The two-person verbal check for tracheal intubation significantly reduces the risk of unrecognized esophageal intubation and has been widely accepted by both intubators and assistants.
- Methodological Innovation: The study is the first to systematically evaluate the feasibility and acceptability of the two-person check, particularly in hospitals of different sizes and configurations.
- Improved Team Collaboration: The two-person check not only enhances the technical accuracy of confirmation but also improves team communication and collaboration, reducing barriers caused by hierarchical team structures.
Research Significance
This study provides a simple and effective solution to reduce the risk of unrecognized esophageal intubation. The two-person check method has both scientific value and broad applicability, particularly in anesthesia and intensive care. In the future, this method is expected to be incorporated into international guidelines for tracheal intubation, becoming a standard part of the operational process.