Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data

Tadahiro Goto, Koichiro Gibo, Yusuke Hagiwara, Hiroshi Morita, David F M Brown, Calvin A Brown 3rd, Kohei Hasegawa, Japanese Emergency Medicine Network Investigators, Takahisa Kawano, Hideya Nagai, Hidenori Higashi, Shojiro Oka, Takashi Matsumoto, Kenzo Tanaka, Shigeki Tsuboi, Yukari Goto, Nobuhiro Sato, Masashi Okubo, Yukiko Nakayama, Taichi Imamura, Yasuaki Koyama, Hiroshi Okamoto, Hiroshi Okamoto, Takuyo Chiba, Yukinori Kato, Hiroshi Kamura, Kazuaki Shigemitsu, Shunichiro Nakao, Kotaro Takebe, Tadahiro Goto, Koichiro Gibo, Yusuke Hagiwara, Hiroshi Morita, David F M Brown, Calvin A Brown 3rd, Kohei Hasegawa, Japanese Emergency Medicine Network Investigators, Takahisa Kawano, Hideya Nagai, Hidenori Higashi, Shojiro Oka, Takashi Matsumoto, Kenzo Tanaka, Shigeki Tsuboi, Yukari Goto, Nobuhiro Sato, Masashi Okubo, Yukiko Nakayama, Taichi Imamura, Yasuaki Koyama, Hiroshi Okamoto, Hiroshi Okamoto, Takuyo Chiba, Yukinori Kato, Hiroshi Kamura, Kazuaki Shigemitsu, Shunichiro Nakao, Kotaro Takebe

Abstract

Background: Although the international guidelines emphasize early and systematic use of rescue intubation techniques, there is little evidence to support this notion. We aimed to test the hypothesis that preceding multiple failed intubation attempts are associated with a decreased success rate on the first rescue intubation in emergency departments (EDs).

Methods: We analysed data from two multicentre prospective registries designed to characterize current ED airway management in Japan between April 2010 and June 2013. All patients who underwent a rescue intubation after a failed attempt or a series of failed attempts were included for the analysis. Multiple failed intubation attempts were defined as ≥2 consecutive failed intubation attempts before a rescue intubation. Primary outcome measure was success rate on the first rescue intubation attempt.

Results: Of 6,273 consecutive patients, 1,151 underwent a rescue intubation. The success rate on the first rescue intubation attempt declined as the number of preceding failed intubation attempts increased (81% [95% CI, 79%-84%] after one failed attempt; 71% [95% CI, 66%-76%] after two failed attempts; 67% [95% CI, 55%-78%] after three or more failed attempts; P(trend) <0.001). In the multivariable analysis adjusting for age, sex, principal indication, change in methods, devices, and intubator specialty, and clustering of patients within EDs, success rate on the first rescue intubation after two failed attempts was significantly lower (OR, 0.56; 95% CI, 0.41-0.77) compared to that after one failed attempt. Similarly, success rate on the first rescue intubation attempt after three or more failed attempts was significantly lower (OR, 0.49; 95% CI, 0.25-0.94) compared to that after one failed attempt.

Conclusion: Preceding multiple failed intubation attempts was independently associated with a decreased success rate on the first rescue intubation in the ED.

Figures

Figure 1
Figure 1
Patients receiving intubations in emergency departments, according the number of failed intubation attempts. All of the 23 patients who died during intubation had cardiac arrest as the primary indication of intubation (i.e., these patients had cardiac arrest prior to the intubation attempts).
Figure 2
Figure 2
First rescue intubation success rates, according to the number of failed intubation attempts. I bars represent 95% confidence intervals. The success rate on first rescue intubation attempts declined as the number of failed intubation attempts increased (81% [95% CI, 79%-84%] after one failed attempt; 71% [95% CI, 66%-76%] after two failed attempts; 67% [95% CI, 55%-78%] after three or more failed attempts; Ptrend <0.001).

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