Abstract：
Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of \'sustained exhaled carbon dioxide\' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
摘要：
在全球范围内开展气道管理的多个学科中，可预防的未识别的食管插管事件导致严重的低氧血症，脑损伤和死亡。这些事件发生在没有经验和有经验的从业者手中。当前的证据表明，未被识别的食管插管发生的频率足以成为主要问题，值得采取协调的方法来解决。通过降低食管插管率可以避免未识别的食管插管的危害，结合提示检测和立即行动，当它发生。使用波形二氧化碳图检测“持续呼出二氧化碳”是排除食管放置预期气管导管的主要方法。当无法检测到持续呼出的二氧化碳时，管道移除应是默认反应。如果默认的导管移除被认为是危险的,建议使用有效的替代技术紧急排除食管插管，同时评估无法检测二氧化碳的其他原因。如果不能实现持续呼出的二氧化碳的及时恢复,则应移除该管。除了技术干预，需要采取策略来解决认知偏见以及在压力情况下个人和团队绩效的恶化，所有从业者都很脆弱。这些指南为预防与所有气道从业者无关的未识别的食管插管提供了建议，临床定位,纪律或病人类型。
