Unrecognised oesophageal intubation: additional human factors and ergonomics solutions

Abstract

regarding unrecognised oesophageal intubation [2].We understand Glenda Logsdail's case involved 'misinterpretation' of capnography without 'sustained exhaled carbon dioxide' soon becoming flat, with the anaesthetist focusing instead on a Grade 1 laryngoscopy view, loss of situation awareness and fixation on one diagnosis (here, anaphylaxis). We would like to add to the authors' solutions included in the editorial.Considering 'engineered solutions', we suggest industry alters the capnograph trace on monitors to shade the area under the curve as already seen on some monitors (Fig. 1). This helps distinguish the capnograph trace from the ventilator airway pressure waveform (Fig. 2), reportedly an issue in Glenda Logsdail's case [2]. We advocate 'universal videolaryngoscopy', which has benefits for skill acquisition, teamwork, communication, non-technical skills

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*

“…Manufacturers of airway monitors are encouraged to support the ability to standardise displays in this manner and to take other steps to increase the distinctiveness of the carbon dioxide waveform (e.g. using a `shaded in´trace while leaving other waveforms as `line only´) [46,151]. The potential for enhanced displays or smart monitors [152],…”

“…Manufacturers of airway monitors are encouraged to support the ability to standardise displays in this manner and to take other steps to increase the distinctiveness of the carbon dioxide waveform (e.g. using a ‘shaded in’ trace while leaving other waveforms as ‘line only’) [ 46 , 151 ]. The potential for enhanced displays or smart monitors [ 152 ], able to use information from gas measurements, pulse oximetry, volume and pressure readings to make a verbal declaration of the need to exclude oesophageal intubation or of the time elapsed since the oxygen saturation has dropped below a specified level should be explored [ 46 , 67 , 153 , 154 ].…”

“…To minimise the risk of misidentification of other variables as the carbon dioxide waveform (e.g. pressure waveforms), efforts should be made to standardise the layout, format and colours of the variables displayed on monitors [8, 11, 151].…”

Application of Ergonomics in Product Design Based on Computer-Aided Design

“…e interaction between machinery and the environment provides a more comprehensive basis for the design and use of the human-machine system by revealing the law of the relationship between the three elements of human, machine, and environment, thereby ensuring the optimization of the overall performance of the human-machine system. It provides a theoretical basis and method for designing a "man-machine-environment" system that is easy and labor-saving, accurate, safe, efficient, and comfortable [12].…”

Human factors and clinical assessment: issues in confirming correct tracheal tube placement

“…We thank Dr Kelly and Professor Cook for their helpful comments [1], which add important detail to our editorial [2]. There is perhaps a slight difference in emphasis as we see the fundamental issue as being to confirm correct placement and not just detect oesophageal placement.…”