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The enduring myth of why a distally placed endotracheal tube always goes into the right mainstem bronchus
Postgraduate Medical Journal ( IF 3.6 ) Pub Date : 2020-12-31 , DOI: 10.1136/postgradmedj-2020-139401 Anthony M-H Ho 1 , Gregory Klar 1 , Glenio B Mizubuti 2
Postgraduate Medical Journal ( IF 3.6 ) Pub Date : 2020-12-31 , DOI: 10.1136/postgradmedj-2020-139401 Anthony M-H Ho 1 , Gregory Klar 1 , Glenio B Mizubuti 2
Affiliation
In an Australian study, the most common mishap with endotracheal tube (ETT) placement was inadvertent endobronchial intubation (ETT placed too deep), more so than oesophageal intubation, accounting for nearly half of all the ETTrelated incident reports. In the prehospital setting in a German study, emergency physicians inadvertently intubated the right mainstem bronchus in 6.7% of their intubations. In patients intubated by an emergency physician or anaesthesiologist in a German emergency department, the incidence of right mainstem intubation was 7%. In that study, the ETT tip was within 2 cm of the carina in another 13% of patients. When an ETT tip is that close to the carina, events such as head flexion can move the ETT up to 3.1 cm (mean 1.9 cm) toward the carina from the neutral position. Furthermore, rostral displacement of the carina because of Trendelenburg positioning (to treat hypotension, to cannulate a central vein or during surgery) or pneumoperitoneum for laparoscopy can result in right mainstem bronchial intubation. The margin of safety is correspondingly small in small patients. Mainstem intubation could trigger bronchospasm, cause hypoxaemia due to a massive shunt and atelectasis, and the increased inspiratory pressure may result in barotrauma and even haemodynamic disturbances. In complex cases (eg, major trauma), it can complicate diagnosis and management of lifethreatening injuries. Endobronchial intubation accounts for 2% of adverse respiratory claims in adults and 4% in children in the American Society of Anesthesiologists’ Closed Claims Database. Inadvertent mainstem intubation is therefore an important discussion topic with learners rotating through anaesthesia, emergency medicine, critical care and surgery. Spanning over 3 decades of our careers, we must have asked hundreds of residents and students in and from Canada, Hong Kong, Brazil and other countries what happens when one places an ETT too deep in the trachea. The answer has always been correct, that it goes into the right mainstem bronchus. However, when asked why specifically the right, the answer has almost always been that the right bronchus subtends a straighter angle with the trachea and has a larger diameter compared with the left. To support their assertion, some learners have volunteered that these are the same reasons why aspirated foreign bodies tend to enter the right mainstem more often, seemingly oblivious to the inconsistency—a lot of foreign bodies are aspirated into the left mainstem whereas a wayward ETT rarely ever enters the left mainstem—in their argument. Further discussion as to the source of that information invariably reveals that it is taught to them by physicians during their undergraduate and/or postgraduate training. This misinformation is also perpetuated in the mainstream media (eg, https:// radiopaedia. org/ articles/ endobronchialintubation).
更新日期：2020-12-31
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