Capnography: No Trace = Wrong Place

The Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) have collaborated to create the video resource Capnography: No Trace = Wrong Place. 

Presented by Professor Tim Cook, the video shares the important message that during cardiac arrest, if a capnography trace is completely flat, oesophogeal intubation should be assumed until proven otherwise.

The College recommends that all clinicians involved in the management of airways should take the time to watch this video and help share this important message. The slideshow presentation from the video is available on request and can be used in departmental meetings.

Recently there have been two patient deaths associated with oesophageal intubation, which are highlighted in Coroner’s Reports available at www.judiciary.uk – more details are available in the video and within the slideshow presentation.

RCoA and DAS also partnered on the ground breaking 4th National Audit Project (NAP4): Major Complications of Airway Management in the United Kingdom, which also discusses cases of undetected oesophogeal intubation.

If you have any questions about the materials please contact: clinicalquality@rcoa.ac.uk

Related Content

Airway Leads
Departmental Airway Leads provide leadership and practical support in all airway-related matters.

Unrecognised oesophageal intubation
Unrecognised oesophageal intubation: the College receives reports to prevent future deaths from the coroner when the coroner is concerned that future deaths could occur unless action is taken. This page details initiatives by the College in response to coroner's reports.

Cappuccini Test
A simple audit relating to supervision of anaesthetists in training and non-consultant career grade doctors.