Successful endotracheal intubation following a failed first attempt during aeromedical retrieval

Abstract

IntroductionFirst attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.MethodsLifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.ResultsOf the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.ConclusionAlthough a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM)

“…However, the small number of cases renders this observation inconclusive. A change of operator is a recognised successful strategy for failed first-pass intubation in both hospital and prehospital practice [25,26]. Physicians from an anaesthetic background recognise that they are likely to have significantly more advanced airway management skills [27], and therefore switching to a 'less experienced' non-anaesthetist operator may be perceived to delay definitive airway management, especially as the initial anaesthetic operator may be best placed to perform subsequent attempts.…”

Anaesthetists in emergency medicine training and emergency department anaesthesia

“…For these reasons, I think it is rare that they would be the best solution to a challenging airway scenario in the ED. I will acknowledge my bias here – LifeFlight aeromedical teams work without access to these techniques and have very high success rates in airway management 10 . There are a number of factors that likely contribute to this which are available to ED teams, such as standardisation of equipment and drugs, checklists, team briefs and the use of cognitive aids 11,12 .…”

“…I will acknowledge my bias here -LifeFlight aeromedical teams work without access to these techniques and have very high success rates in airway management. 10 There are a number of factors that likely contribute to this which are available to ED teams, such as standardisation of equipment and drugs, checklists, team briefs and the use of cognitive aids. 11,12 There is value in a focus on simple things done well with strategic consideration of alternatives that could also be employed by resource limited hospitals such as road transfer to a centre with anaesthetic capability.…”