Unrecognised oesophageal intubation: a review

Oesophageal intubation is dangerous if not promptly identified and managed. It often results from human error and inadequate education. An advanced technologies can mitigate the risk of this serious complication and enhance patient safety. This narrative review evaluated contemporary publications concerning unrecognised oesophageal intubation in the surgical theatre. PubMed, Scopus, and the Cochrane Library were searched for relevant articles published from 2010 to 2025, excluding non-English manuscripts, case reports, and studies lacking pertinent data. The effectiveness of capnography, video laryngoscopy, and simulation training was analysed to determine intubation rates across various clinical settings. The narrative review indicated that the rates of unrecognised oesophageal intubation range from 2.9% to 16.7%, and are associated with increased mortality. The implementation of video laryngoscopy reduced these rates by approximately 50%, while simulation training improved first-attempt intubation success. The findings underscore the necessity of incorporating advanced monitoring systems and simulation-based training into anaesthesia protocols to reduce the risks associated with overlooked oesophageal intubation. This fosters a safety-oriented culture and utilises technological innovations to significantly improve patient outcomes and decrease the incidence of this severe complication.

Oesophageal intubation; Human factors; Monitoring; Patient safety; Simulation; Training

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