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J Clin Monit Comput

DOI 10.1007/s10877-014-9583-5


Detection of endobronchial intubation by monitoring the CO2

level above the endotracheal cuff
Shai Efrati Israel Deutsch Nathan Weksler
Gabriel M. Gurman

Received: 26 February 2014 / Accepted: 7 May 2014

Springer Science+Business Media New York 2014

Abstract Early detection of accidental endobronchial

intubation (EBI) is still an unsolved problem in anesthesia
and critical care daily practice. The aim of this study was to
evaluate the ability of monitoring above cuff CO2 to detect
EBI (the working hypothesis was that the origin of CO2 is
from the unventilated, but still perfused, lung). Six goats
were intubated under general anesthesia and the ETT
positioning was verified by a flexible bronchoscope. The
AnapnoGuard system, already successfully used to detect
air leak around the ETT cuff, was used for continuous
monitoring of above-the-cuff CO2 level. When the ETT
distal tip was located in the trachea, with an average cuff
pressure of 15 mmHg, absence of CO2 above the cuff was
observed. The ETT was then deliberately advanced into
one of the main bronchi under flexible bronchoscopic
vision. In all six cases the immediate presence of CO2
above the cuff was identified. Further automatic inflation of
the cuff, up to a level of 27 mmHg, did not affect the
above-the-cuff measured CO2 level. Withdrawal of the
ETT and repositioning of its distal tip in mid-trachea
caused the disappearance of CO2 above the cuff in a
maximum of 3 min, confirming the absence of air leak and
the correct positioning of the ETT. Our results suggest that
S. Efrati (&)
Research and Development Unit, Assaf Harofeh Medical Center,
Affiliated with the Sackler School of Medicine, Tel-Aviv
University, 70300 Zerifin, Israel
e-mail: efratishai@013.net
I. Deutsch
Hospitech Respiration Ltd., Petah Tikva, Israel
N. Weksler  G. M. Gurman
Division of Anesthesiology and Critical Care, Myney
Hayeshuah, Bnei Brak, Ben-Gurion University of the Negev,
Beersheba, Israel

measurement of the above-the-cuff CO2 level could offer a

reliable, on-line solution for early identification of accidental EBI. Further studies are planned to validate the
efficacy of the method in a clinical setup.
Keywords Endobronchial  Intubation  One lung  CO2 
Endotracheal tube

1 Introduction
Intubation of a main bronchus, more frequently on the
right, is a common incident during tracheal intubation for
general anesthesia and/or prolonged mechanical ventilation
The pathological consequences of one lung intubation
are mainly reduction of blood oxygenation, appearance of
tension pneumothorax (because of hyperinflation of the
intubated lung), and an increase in the post-intubation
pulmonary complications, including atelectasis and
A report by the Australian Incident Monitoring Study
(AIMS) on 2000 patients found endobronchial intubation
(EBI) to be the most common incident involving tracheal
intubation [1]. A second AIMS study [2], on 2,947 patients,
found that accidental EBI accounted for 3.7 % of all
incidents reported. The relatively high incidence is mainly
due to the incertitude of the anatomical distance between
the teeth and the carina. That is why relying on fixed
measurement does not guarantee proper positioning in all
patients, as Owen and Cheney proposed in their study [3],
does not cover those patients who do not belong to the
normal range of height. Moreover, physical examination, including auscultation of the chest wall, is a nonobjective measure highly dependent on the physicians


J Clin Monit Comput

experience. For example, in a study done by Sitzwohl et al.,

first year residents missed EBI by auscultation in 55 % of
the cases, which was significantly worse than experienced
anaesthetists [6].
Neither clinical auscultation [5, 8], monitoring of oxygen saturation [9], nor end-tidal CO2 [10, 11] offers an
accurate and rapid method of identifying EBI. Furthermore, any change in the patients head or neck position can
lead to migration of the ETT. Conrardy et al. reported that
neck flexion can advance the tube up to 3.1 cm toward the
carina, exposing the patients to higher risk of EBI [12].
Accordingly, there is a need for an objective, non-invasive
method that identifies and alarms the medical staff early
when the ETT is mal-positioned.
The present study proposes a new method of early
detection of bronchial location of the ETT distal tube,
using a system that identifies the presence of CO2 just
above the ETT cuff when there is no leak around the cuff.
We hypothesized that the CO2 from the non-ventilated lung
can be detected above the cuff once main stem intubation
accidentally occurs.

2 Methods
The study included six healthy goats at the age of 2 years.
The goats were not pregnant or lactating, and had a mean
weight of 50 kg. The experiment was conducted in the
Research and Development Unit of Assaf Harofeh Medical
Center, Israel. All the animals included in the study were
maintained according to the guidelines of the Local Ethics

Fig. 1 The three lumen

endotracheal tube use for above
cuff CO2 readings


Committee for Animal Experimentation, and the experimental protocol was approved by the latter.
Before anesthesia, the physiological parameters of each
animal were measured and found to be within normal
range: heart rate around 50/min, body temperature 38.0 C,
and respiratory rate around 20/min.
Each goat was anesthetized using i.v. ketamine
1011 mg/kg, midazolam 0.2 mg/kg, Lidocaine 0.2 mg/kg,
and atropine 0.5 mg i.v. After tracheal intubation with an
extended tube of 50 cm, especially prepared for this study,
the animal was kept anesthetized with Isoflurane 12 % in
oxygen, the head up 20 degrees and mechanically ventilated with a tidal volume of 7 ml/kg.
2.1 Endotracheal tubes and device used for above cuff
CO2 reading
A modified version of the AnapnoGuard system ETT
(Hospitech Respiration Ltd., Petah Tikva, Israel) was used.
As illustrated in Fig. 1, in order to enable successive CO2
readings (air samples taken from the space above the cuff
and below the vocal cords to the AnapnoGuard system CO2
analyzer), the ETT has 2 additional lumens: one for CO2
readings (ventral lumen) while the other (dorsal lumen) is
split into two at the distal end, used for suctioning of
secretions. The lumens on both sides also serve as venting
lumens, meaning that when the system is used for suctioning secretions, the ventral (CO2) lumen serves for
venting while suctioning with the dorsal suction lumen and
vice versa. The CO2 samples are pumped into the CO2
analyzer via the CO2/vent lumen or the suction lumen.

J Clin Monit Comput

3 Results

Fig. 2 Tracheal tube positioning and origin of CO2 during endobronchial intubation

Having this venting capability reduces the chances of

lumen occlusion that usually happens with standard suction
ETTs due to vacuum, and adherence to the tracheal wall is
The AnapnoGuard system is an innovative respiratory
guard system that automatically monitors and controls the
ETT cuff pressure. The cuff pressure that seals off the
trachea is set by measurement of CO2 levels above the cuff
[13]. The optimal ETT cuff pressure is the minimal pressure needed to prevent CO2 leakage from the lungs to the
2.2 Tube positions
After stabilizing the animals vital signs and verification of
the perfect sealing off of the airways (no CO2 leak above
the cuff, at a maximal cuff pressure of 15 mmHg), the tube
was advanced into one of the main bronchi (the right one in
four cases, the left in two cases) under flexible bronchoscopic vision. In this new ETT distal tip location, the cuff
sealed off only the intubated main bronchus (Fig. 2). The
above or below carina position of the ETT tip tube was
verified using a flexible bronchoscope. The AnapnoGuard
system upper limit of CO2 scale is 6 mmHg (consider to be
a high significant leakage).
After the ETT was positioned in the main bronchi,
above cuff CO2 was continuously measured by the AnapnoGuard system for 4 min. If CO2 leakage was detected the
cuff was inflated to a maximal preset cuff pressure of
27 mmHg and above cuff CO2 was re-measured in the next
4 min. Once it done, the ETT was repositioned to the trachea and in the following 3 min the cuff pressure was
reduced by the AnapnoGuard system to the minimal
pressure needed to prevent CO2 leakage.

All animals were hemodynamically stable and completed

all study procedures. In each endobronchial ETT position
the above-the-cuff CO2 was detected in each animal in less
than 2 min; partial pressure was 6 mmHg in each of the 6
experiments (6 mmHg is the upper limit of the CO2 scale
in the AnapnoGuard system, but most probably the true
CO2 level at this stage of the experiment was much higher,
closer to the arterial or alveolar level). Because of the
system detection of CO2 above the cuff, the AnapnoGuard
system automatically increased the cuff pressure to an
average of 27 mmHg (range 2229.5), but the system
continued to detect significant CO2 levels above the cuff.
Then the ETT distal tip was once again relocated above
the carina and its position reconfirmed by flexible bronchoscopy; in the next 3 min the CO2 above the cuff disappeared and the automatic regulation of cuff pressure
permitted its decrease to an average level of 13.6 mmHg.
The sequence of procedures during the test is summarized in Table 1.

4 Discussion
The AnapnoGuard system has already been clinically tried
during general anesthesia and proven to be a reliable
method of assuring the optimal cuff pressure that will avoid
Table 1 Sequence of procedures, average cuff pressure, and CO2
level above the ETT cuff
CO2 level


Location of
ETT distal



Induction of

15 (Range


Tracheal intubation



(4 times
Rt, 2 times

ETT advance under



27 (Range


Automatic inflation
of the cuff to a
preset maximal


0 (in max.
3 min)



ETT repositioning


The current scale of the capnograph in the AnapnoGuard system is

06 mmHg. We speculate that the real CO2 level was much higher
probably close to the arterial or alveolar level


J Clin Monit Comput

air leak around the tube when its distal tip is located
between the vocal cords and the carina [13]. In this
experimental setup the only difference in comparison to
any other anesthesia technique was the use of a special
ETT, with side ports connected to a system that continuously measured the CO2 level above the cuff and automatically adjusted the cuff pressure to a level that avoided
air leak. In addition, the length of the ETT used was greater
than that in use for humans because of the anatomic conformation of goats.
Our hypothesis for the present study was that once the
ETT distal tip accidentally slips into one of the main
bronchi, the AnapnoGuard system would react by identifying CO2 above the cuff. The origin of the CO2 in this
case is expected to be the unventilated lung, which at least
for the initial period of time is still perfused. Suggett et al.
[14] have demonstrated, in their dog model, that even at the
plateau phase, when the perfusion to the unventilated lung
is significantly decreased, CO2 is still being diffused. Since
during EBI, the malpositioned cuff cannot achieve complete sealing of the non-intubated lung, above cuff CO2
leak can be detected.
The proposed method of early detection of accidental
EBI has the advantage of being simple to use, noninvasive,
and suitable for any intubated patient. It displays on-line
the CO2 level above the cuff tube and thus can identify the
endobronchial position of the distal tip after only a very
short delay.
Each of the already proposed techniques to be used for
the purpose of identification of EBI has flaws and limitations. For instance, the Rapiscope technique [15] could not
be used continuously. The reflectometry method [16] does
not offer reliable results in the presence of bronchial
secretions or a tracheobronchial tumor. Finally, the video
imaging method [17] is limited in chest asymmetry; in
addition, in the presence of air leak this method becomes
unusable. Recently, two of the current investigators (NW,
GMG) reported the use of a new monitoring method for
detection of EBI by transforming the lung sounds recorded
by four piezoelectric acoustic sensors into a processed
electronic signal. These studies showed a good correlation
between the real location of the ETT distal tip and the
results of the signal analysis, in cases of both endotracheal
tubes [18] and double lumen tubes [19], but the proposed
method demanded the use of microphones and a complicated algorithm.
We suggest that the AnapnoGuard system could detect
accidental EBI at a very early stage and offers a valid
alternative to the already proposed methods to be used for
this purpose. It can be easily used by the average physician
and its display is easy to understand. One possible incident
during its use could be the accumulation of secretions
around the cuff, but the ETT used with the AnapnoGuard


system is provided with a special extra lumen, with two

distal openings located just above the cuff, through which
secretions are periodically aspirated. As detailed above, the
primary intended use of the AnapnoGuard system is for
ETT cuff pressure optimization by monitoring above cuff
CO2 levels [16]. In addition, the AnapnoGuard system, by
assuring optimal cuff sealing and continuous analysis of
gradient pressure between the cuff and the ventilator, can
detect the degree of intra-luminal ETT obstruction [20].
Moreover, the AnapnoGuard system with the special ETT
enables effective suction of secretion from the subglottic
space. Therefore, detection of EBI is an additional beneficial feature gained by monitoring above cuff CO2. The
cost of the special ETT, with the extra 2 lumens, is similar
to the costs of the other high end suction ETTs. However,
the AnapnoGuard system is capital equipment that possessed additional cost. The special ETTs are FDA and CE
(European) approved. The AnapnoGuard system has CE
approval and is currently in the process of receiving FDA
There are certain situations in which the CO2 method
may be misleading if not recognized appropriately. There
are two conditions that may be associated with continued,
unadjusted, above cuff CO2 readings even though it is not
EBI (false positive) and two condition where CO2 will not
be detected even though it is EBI (false negative). The first
condition where CO2 will be continuously recorded is cuff
rupture. That can be easily detected by the low non-filled
cuff pressure. The second condition is proximal malposition of the ETT (cuff is within or above the vocal cords).
The proximal malposition can be easily detected by looking at the insertion depth of the ETT at tooth line. On the
other hand, if secretions are blocking the sampling lumen,
there will be no CO2 reading. That can also be easily
detected by the AnapnoGuard system since it will alert that
the lumen is blocked (very unusual with the 3-lumen
special ETTs). Another possible incident for misdiagnosis
of EBI, false negative, could be when only the tip of the
ETT is located the main-stem ventilating one lung, while
the cuff is on the carina occluding both bronchi. In this
case, it might be possible that CO2 will not leak and the
ineffective ventilation will not be detected. Accordingly,
since there is no single monitoring method that have 100 %
accuracy, it is very important that as many signs as possible need to be frequently monitored in order to detect and
prevent EBI.
In conclusion, we propose a new method for early
detection of accidental EBI by continuous measurement of
CO2 level above the ETT cuff. This new use of the AnapnoGuard system could be added to the already proven
indication of detection of air leak around the cuff in intubated patients, without any need to change any of the
details of the proposed system for this task.

J Clin Monit Comput

We suggest that when using the proposed system,

appearance of CO2 above the cuff, in the absence of an air
leak (at high cuff pressures), might indicate the need to
withdraw the ETT. However, this is a preliminary report
and further studies are needed to evaluate the method in
different clinical and experimental settings.
ration, Ltd.

The study was supported by Hospitech Respi-

Conflict of interest
piration, Ltd.

SE and ID are shareholders in Hospitech Res-

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