Airway/original researchAssociation Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study
Introduction
Intubation is a critical intervention performed in the emergency department (ED). Previous studies have described adverse events associated with intubation in this clinical setting, such as airway trauma, esophageal intubation, aspiration, hypoxemia, hypotension, dysrhythmia, and cardiac arrest.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Despite emphasis on “first-pass intubation success,” other studies suggest that 3% to 12% of all ED intubations require multiple laryngoscopic efforts.2, 4, 5, 7, 8, 11
International anesthesia consensus standards recommend limiting airway management efforts to a total of 3 laryngoscopy attempts, with subsequent rescue use of supraglottic or alternate airway devices.12, 13 However, there has been little clinical evidence to support this strategy in the ED, where airway management is typically performed by emergency physicians on acutely ill patients. The relationship between multiple ED intubation attempts and adverse patient outcomes has not been studied, to our knowledge.
We aimed to determine whether multiple intubation attempts are associated with airway-associated adverse events in patients undergoing intubation in the ED.
Section snippets
Study Design and Setting
This study was a secondary analysis of the Japanese Emergency Airway Network Registry, a prospective observational multicenter data registry designed to characterize the current ED airway management across Japan. The study setting, methods of measurement, and measured variables have been reported previously.14 In summary, the registry is a consortium of 11 academic and community medical centers from different geographic regions across Japan. All 11 EDs were staffed by emergency attending
Results
During the 18-month period, there were 2,788 subjects requiring emergency airway management (Figure). Among these, the database recorded 2,710 intubations (capture rate 98%). We excluded 94 patients undergoing initial airway management by nasal intubation, cricothyrotomy, or accessory devices. We included the remaining 2,616 patients studying the analysis.
The mean age of patients receiving intubation was 64 years (Table 1). Most intubations involved medical emergencies. One third of patients
Limitations
Surveillance systems such as that used in this study are subject to self-reporting bias, leading to an underestimation of adverse event rates.18 However, real-time independent monitoring of ED airway management is difficult to accomplish. We used a previously applied self-reporting system with structured data forms, uniform definitions, and a high capture rate.4 We believe that these data represent the best available data. Despite these limitations, we detected a high rate of adverse events. We
Discussion
Despite its ubiquitous presence in contemporary emergency medicine practice, many vital questions about ED airway management remain unanswered.19 Ironically, the majority of scientific evidence of emergency airway management originates from out-of-hospital and anesthesia settings; we lack similar insights about airway management in the ED.20, 21, 22, 23, 24, 25, 26 In the out-of-hospital and anesthesia literature, tracheal injury, hypoxemia, and other intubation-related adverse events have been
References (33)
- et al.
Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway SocietyPart 2: intensive care and emergency departments
Br J Anaesth
(2011) - et al.
Emergency airway management: a multi-center report of 8937 emergency department intubations
J Emerg Med
(2011) - et al.
Complications of emergency intubation with and without paralysis
Am J Emerg Med
(1999) - et al.
Airway management in the emergency department: a one-year study of 610 tracheal intubations
Ann Emerg Med
(1998) - et al.
Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts
Ann Emerg Med
(2005) - et al.
Emergency airway management in Japan: interim analysis of a multi-center prospective observational study
Resuscitation
(2012) - et al.
A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient
Ann Emerg Med
(1987) - et al.
Recommended guidelines for uniform reporting of data from out-of-hospital airway management: position statement of the National Association of EMS Physicians
Prehosp Emerg Care
(2004) Emergency airway management: the need to refine—and redefine—the “state of the art.”
Resuscitation
(2012)- et al.
Out-of-hospital airway management in the United States
Resuscitation
(2011)
Outcomes after out-of-hospital endotracheal intubation errors
Resuscitation
How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations?
Ann Emerg Med
Preventable morbidity and mortality from prehospital paralytic assisted intubation: can we expect outcomes comparable to hospital-based practice?
Prehosp Emerg Care
Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation
Resuscitation
Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation
Ann Emerg Med
Emergency medicine in Japan
Ann Emerg Med
Cited by (225)
Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study
2023, American Journal of Emergency MedicineCricothyrotomy in difficult airway management: A narrative review
2023, Trends in Anaesthesia and Critical CareIncidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study
2023, American Journal of Emergency MedicineVariability in Pediatric Emergency Airway Management Laryngoscopy Modality: Clinical Equipoise or Unwarranted Clinical Variation?
2023, Annals of Emergency Medicine
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was supported by a grant from St. Luke's Life Science Institute and a grant from Massachusetts General Hospital and Brigham and Women's Hospital. The study sponsors had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the article; or in the decision to submit the article for publication.
Please see page 750 for the Editor's Capsule Summary of this article.
Supervising editor: Henry E. Wang, MD, MS
Author contributions: KH, KS, and DFMB conceived the study. KH obtained research funding. KH, YH, TC, HW, and CAB supervised the conduct of the trial and data collection. YH, TC, and HW managed the data, including quality control. YH and HW provided statistical advice on study design and analyzed the data. KH chaired the data oversight committee. KH drafted the article, and all authors contributed substantially to its revision. KH takes responsibility for the paper as a whole.
A feedback survey is available with each research article published on the Web at www.annemergmed.com.
A podcast for this article is available at www.annemergmed.com.
Publication date: Available online April 28, 2012.