Intended for healthcare professionals


Capnography prevents avoidable deaths

BMJ 2019; 364 doi: (Published 05 February 2019) Cite this as: BMJ 2019;364:l439
  1. T M Cook, consultant in anaesthesia and intensive care medicine1,
  2. W Harrop-Griffiths, consultant anaesthetist2
  1. 1Royal United Hospital Bath NHS Foundation Trust, Bath, UK
  2. 2Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to: T M Cook: timcook007{at}

“No trace=wrong place”

The continuously detectable presence of carbon dioxide in exhaled breath is widely accepted as the best method for confirming that a tracheal tube is correctly placed. However, more than 30 years after the introduction of capnography, patients are still dying because of unrecognised oesophageal intubation or tracheal tube displacement. These deaths are occurring either through failure to use this reliable technology or lack of education about the causes of an absent capnograph waveform.

Last year NHS Improvement updated its list of “never events” to include undetected oesophageal intubation resulting from failure to use capnography or to act on an abnormal waveform.1 The addition is currently suspended for clarification2 pending agreement with perinatologists on whether a lowest age or weight limit for its use should apply. We believe that this never event should be reintroduced as a matter of urgency.

The use of waveform capnography is mandatory during anaesthesia in the UK, and …

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