Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts

Abstract

Background Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS’s association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services. Methods This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data. Results Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66–1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications. Conclusion FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.

A prospective, pragmatic non‐inferiority study of emergency intubation success with the single‐use i‐view versus standard reusable video laryngoscope

“…Future studies would also benefit from physiological end point measurements in addition to first-pass success. 22…”

“…Existing data do not adequately quantify first‐pass success in the deployed setting. Future studies would also benefit from physiological end point measurements in addition to first‐pass success 22 …”

The i‐gel® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID‐19 pandemic

“…23,24 Successful first-pass endotracheal tube placement is associated with responder experience and volume of ETIs performed, with success rates in excess of 80% in high-volume EMS systems. [25][26][27] In this study, the volume of ETIs is relatively low compared to high volume systems, where hundreds of intubations are performed annually.…”

Should videolaryngoscopy become standard practice to facilitate tracheal intubation in anaesthesia, critical care and emergency care?

“…4,5 The proportion of successful intubations on the first attempt has been seen as a performance measure, and not unexpectedly, with more intubation attempts, the prevalence of complications increases. 6,7 In recent years, the use of videolaryngoscopy has emerged as a means of facilitating ETI, and its use is a part of many airway protocols, both in hospital and in pre-hospital settings. Recently, two important large randomized controlled trials have been published examining the use of videolaryngoscopy compared with direct laryngoscopy.…”

“…Some of these complications may be related to the administration of the drugs used to facilitate ETI, but failure to place the tube may result in hypoxia, hypoventilation and ultimately cardiac arrest 4,5 . The proportion of successful intubations on the first attempt has been seen as a performance measure, and not unexpectedly, with more intubation attempts, the prevalence of complications increases 6,7 . In recent years, the use of videolaryngoscopy has emerged as a means of facilitating ETI, and its use is a part of many airway protocols, both in hospital and in pre‐hospital settings.…”