Factors associated with first-pass success of emergency endotracheal intubation

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Abstract

Study objective

Endotracheal intubation is frequently performed in emergency departments (EDs). First-pass success is important because repeated attempts are associated with poor outcomes. We sought to identify factors associated with first-pass success in emergency endotracheal intubation.

Methods

We analyzed emergency orotracheal intubations on adult patients in an ED located in South Korea from Jan. 2013 to Dec. 2016. Various operator-, procedure- and patient-related factors were screened with univariable logistic regression. Using variables with P-values less than 0.2, a multiple logistic regression model was constructed to identify independent predictors.

Results

There were 1154 eligible cases. First-pass success was achieved in 974 (84.4%) cases. Among operator-related factors, clinical experience (OR: 2.93, 5.26, 3.80 and 5.71; 95% CI: 1.62–5.26, 2.80–9.84, 1.81–8.13 and 2.07–18.67 for PGY 3, 4 and 5 residents and EM specialists, respectively, relative to PGY 2 residents) and physician based outside the ED (OR: 0.10; 95% CI: 0.04–0.25) were independently associated with first-pass success. There was no statistically or clinically significant difference for first-pass success rate as determined by operator's gender (83.6% for female vs. 84.8% for male; 95% CI for difference: −3.1% to 5.8%). Among patient-related factors, restricted mouth opening (OR: 0.47; 95% CI: 0.31–0.72), restricted neck extension (OR: 0.57; 95% CI: 0.39–0.85) and swollen tongue (OR: 0.46; 95% CI: 0.28–0.77) were independent predictors of first-pass success.

Conclusions

Operator characteristics, including clinical experience and working department, and patient characteristics, including restricted mouth opening, restricted neck extension and swollen tongue, were independent predictors of first-pass success in emergency endotracheal intubation.

Introduction

Endotracheal intubation is one of the most important critical interventions performed in the emergency department. While it is essential for securing the airway and providing respiratory support in many clinical conditions, it is also associated with various adverse events ranging from transient desaturation to the death of a patient.

It has been emphasized that successful intubation at the first attempt (first-pass success) should be sought especially in the emergency department where most of the patients being intubated are already critically ill. This has been supported by previous studies reporting the link between repeated intubation attempts and various adverse outcomes [1], [2], [3], [4].

First-pass success can be influenced by various factors [5], [6]. Further knowledge about these influences can be useful in predicting high risk airway procedures as well as in improving overall quality of endotracheal intubation in emergency departments. We sought to assess the association between first-pass success rate and various characteristics of operators, procedures and patients in emergency endotracheal intubation.

Section snippets

Study design

This is a retrospective observational study analyzing emergency airway records of a single emergency department in South Korea from Jan. 2013 to Dec. 2016. The institutional review boards of the facility approved the study and provided a waiver of informed consent.

Study setting, data source and study population

The study facility was a tertiary academic hospital in South Korea with an annual emergency department visit of greater than 80,000 patients per year. Emergency endotracheal intubations were primarily performed by emergency medicine

Results

Table 1 describes the whole study population (N = 1154). Overall, more patients were men than women (61.4% vs. 38.6%) with a median age of 72 years (IQR, 58–80 years). Almost half of the cases were crash airway situation (N = 553, 47.9%). First orotracheal intubation was attempted by physicians with a variety of clinical experience (PGY2, PGY3, PGY4, PGY5 and EM specialist). 409 cases (35.4%) were performed by female physicians and only 30 (2.6%) cases were attempted by non-ED physicians.

Discussion

In this study, various factors predictive of first-pass success of emergency endotracheal intubation were identified. However, only several operator-related factors (experience level and clinical department) and patient-related factors (restricted mouth opening, restricted neck extension and swollen tongue) were identified as independent predictors.

The results of the study support previous findings. The association between operators’ clinical experience and first-pass success has been reported

Conclusion

Various operator- and patient-related factors were predictive of first-pass success of emergency endotracheal intubation. Operators’ experience level and clinical department and restricted mouth opening, restricted neck extension and swollen tongue were identified as independent predictors.

Declaration of Competing Interest

The authors declare no conflicts of interest.

Acknowledgements

We sincerely thank Sarah Hearne and all the others for encouraging us to revise our original paper.

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