Pass Intubation Success Research Articles

Effect of cooled tracheal tubes on time to intubate and first pass intubation success in novice intubators: A randomized crossover manikin study

Polyvinyl chloride (PVC) tracheal tubes (TTs) may change in stiffness with changing temperatures. Cooling an TT may increase its rigidity and may assist in maintaining its slope at the tip. In this study, we aim to investigate the effects of a cooled TT on intubation time and first pass success. In a randomized cross-over design, senior medical students without prior intubation experience performed intubation with a direct laryngoscope on a manikin. During the first group's intubations, cooled TTs were used first and then room temperature TTs, while the second group performed it vice versa. The primary outcome was the time to intubation. As secondary outcomes, first pass success, esophageal intubation, and dental click were measured. The study included 21 participants. Cooled TT intubations (61.9%) had significantly higher first-pass success rates than room temperature TT intubations (33.3%) (p = 0.031). When room temperature TT was used for intubations, the mean time to intubation was 14.33 (95% CI 5.59–23.08) seconds longer than when cooled TT was used (p = 0.003). In terms of esophageal intubation and dental click rates, there was no statistically significant difference between the groups (p = 0.754, p = 0.99, respectively). In this manikin study, we observed that novice intubators performed intubation with improved time to intubate and higher first pass success using cooled TT.

A Prospective Comparative Study of Laryngeal Glottic View Using the Vie Scope® versus Standard Macintosh Laryngoscope in Morbidly Obese Patients.

The visualization of the glottis may be inadequate in morbidly obese patients when a standard Macintosh blade laryngoscope (MCL) is used. The Vie Scope® (VS) is a novel type laryngoscope consisting of a straight, enclosed, illuminated tube that offers intubation via a bougie using the paraglossal technique. In this prospective, nonrandomized comparative study, we tested the research hypothesis that the VS may improve visualization of the glottic larynx in comparison to the MCL. After obtaining institutional ethics committee approval, 60 morbidly obese patients (BMI >40 kg/m2) undergoing elective non-head and neck surgery were included in the study. After induction of general anesthesia (GA), the glottic visualization was performed using the two laryngoscopes in succession, first MCL size 3 or 4 followed by the VS and was assessed using the modified Cormack-Lehane scale. Tracheal intubation was performed using the VS The first pass intubation success and the total success rate was recorded only for the VS Intubation time was not measured because of the paired study design. Mean demographic data included: age 41.9±8.2 years, height 171.2±10.2 cm, weight 129.9±21.6 kg, BMI 44.95±3.85 kg/m2. Using MCL, Cormack-Lehane grade 1 was observed in 36 (60%) cases; grade 2 in 7/60 (11.6%); grade 3 in 13/60 (21.7%); and grade 4 in 4/60 (6.7%). Poor laryngeal views represented by grades 3 and 4 were observed in 28.4% of patients with the MCL. Grades obtained with the VS were all grade 1 (100%). The first attempt intubation success was in 58/60 (96.7%) with the VS. No complications were observed. The Vie Scope® laryngoscope, using the paraglossal technique of tracheal intubation, significantly improves visualization of the vocal cords in morbidly obese patients compared to the standard Macintosh laryngoscope.

The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study

IntroductionEndotracheal intubation (ETI) is an infrequent but key component of prehospital and retrieval medicine. Common measures of quality of ETI are the first pass success rates (FPS) and ETI on the first attempt without occurrence of hypoxia or hypotension (DASH-1A). We present the results of a multi-faceted quality improvement program (QIP) on paramedic FPS and DASH-1A rates in a large regional critical care transport organization.MethodsWe conducted a retrospective database analysis, comparing FPS and DASH-1A rates before and after implementation of the QIP. We included all patients undergoing advanced airway management with a first strategy of ETI during the time period from January 2016 to December 2021.Results484 patients met the inclusion criteria during the study period. Overall, the first pass intubation success (FPS) rate was 72% (350/484). There was an increase in FPS from the pre-intervention period (60%, 86/144) to the post-intervention period (86%, 148/173), p < 0.001. DASH-1A success rates improved from 45% (55/122) during the pre-intervention period to 55% (84/153) but this difference did not meet pre-defined statistical significance (p = 0.1). On univariate analysis, factors associated with improved FPS rates were the use of video-laryngoscope (VL), neuromuscular blockage, and intubation inside a healthcare facility.ConclusionsA multi-faceted advanced airway management QIP resulted in increased FPS intubation rates and a non-significant improvement in DASH-1A rates. A combination of modern equipment, targeted training, standardization and ongoing clinical governance is required to achieve and maintain safe intubation by paramedics in the prehospital and retrieval environment.

High ​performance prehospital ​airway ​management: Raising the ​bar with ​education, ​rapid ​sequence ​intubation, ​suction ​assisted ​laryngoscopy ​airway ​decontamination, ​video ​laryngoscopy, and ​skills ​proficiency

BackgroundOur prehospital EMS system has focused on prehospital airway management, with the advent of rapid sequence intubation and video laryngoscopy. Through education and continuous quality improvement intubation success rates using the “Glidescope Go” device have continued to improve and remain the primary tool for airway management in our system. ObjectiveOur objective was to demonstrate how education, rapid sequence intubation (RSI), suction-assisted laryngoscopy airway decontamination (SALAD), video laryngoscopy (VL), and skills proficiency can be used together to systemically improve paramedic airway management success to nearly 100%. MethodsStudy Design: Retrospective cohort of airway management procedures performed by paramedics on prehospital patients. Setting: 10 New Jersey paramedic units. Population: Patients that had airway management completed by paramedics from 1/1/2020 to 12/31/2021. Data Analysis: We analyzed the use of RSI, first pass intubation success rates, overall intubation success rates, supraglottic airway use (i-gel®), and overall airway management success rates. Historical annual first pass success rates are also included for context. ResultsThe database contained 990 patients. Of these patients the first pass intubation success rates were 92.7% over the study period. The overall intubation success rates were 98%, and intubation success rates using RSI were 99%. Backup supraglottic airways were placed in remaining cases, bringing overall airway management success rates to 99.5%. ConclusionWe found that paramedic intubation success rates using SALAD and VL were at 98%. A prehospital airway management strategy focused on education and skills proficiency can minimize the risk of this important skill and has potential to improve patient outcomes.

Direct versus Video Laryngoscopy during Simulated Mechanical Chest Compressions: A Randomized Crossover Trial.

Sir, Mechanical compression devices are often utilized for cardiopulmonary resuscitation (mCPR) in the emergency department (ED). We conducted an investigation to evaluate the time to intubation, operator confidence, and success rates of endotracheal intubation with video laryngoscopy (VL) versus direct laryngoscopy (DL) during simulated mCPR. This was a prospective, randomized crossover trial. Thirty consenting emergency physicians were surveyed about experience/technique preferences, and then performed intubations on a moderately difficult airway and adult Manikin during simulated mCPR (LUCAS 3.0) at 100 compressions/min. Technique order was randomized. Intubation time defined as blade pick up until the tube cuff inflated. Participants rated success confidence on a 5-point scale (high = 5) and provided the Cormack/Lehane grade (difficult = 3 or 4). The scenario was repeated with the alternate technique. The categorical variables analyzed by the Chi-square and continuous variables by t-tests. Multivariate logistic regression was performed to control for confounding. There were 30 participants: 73% with 1–5 years of experience, 40% with >100 prior intubations, 73% utilized mac 4 direct blade, and 60% prefer VL during cardiopulmonary resuscitation (CPR). Participants had first pass intubation success for all but one of the attempts with both modalities (NS). Participants more often expressed “high confidence” that intubation was successful for direct 60% versus video 77% (P = 0.2), but they more often rated the airway “difficult” for direct (40% vs. 10%; P = 0.01). Within bivariate analysis, mean time difference to intubate was less for DL versus VL (−6.8 s; P = 0.02). There were no significant associations between time differences to intubate for the following variables: experience (P = 0.6), >100 prior intubations (P = 0.8), blade size (P = 0.3), preferred technique (P = 0.8), high confidence successful DL (P = 0.5), high confidence successful VL (P = 0.7), rating of difficult view DL (P = 0.8), and rating of difficult view VL (P = 0.9). In the multivariate logistic regression with time difference as the dependent variable, there were no statistically significant independent variables. Several prior investigators have reported the success rates of endotracheal intubation with and without chest compressions.[1–5] Han etal. described that VL was superior to DL in simulated CPR settings and that interruption of chest compressions was seemingly unnecessary.[1,3] However, within our literature search, we did not find earlier studies comparing VL versus DL mCPR. In contrast to the findings of Han etal., we observed a lower mean time difference to intubation for DL versus VL during simulated mCPR in our current study, although such differences are unlikely clinically meaningful. On the other hand, participants in our study group were more confident that intubation was successful when using VL. The limitations of our study include single center site, small sample size, participants had varying prior intubation experience, and the high-fidelity Manikin may not replicate all the aspects of difficult intubation in the setting of actual CPR in the ED. Future studies evaluating DL versus VL during mCPR should be conducted in the clinical setting. Research quality and ethics statement The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Use of Video Laryngoscopy to Improve Intubation Success on Neo-pediatric Transport: a QI Initiative

<h3>Introduction</h3> We aimed to implement video laryngoscopy (VL) during neonatal and pediatric transports to improve first pass intubation success rates from a baseline period of Jan 2018- July 2019 to a post intervention period of May 2020-Apr 2021. <h3>Methods</h3> We implemented the Concurrent Media Access Control (C-MAC®) VL training with didactic sessions and simulation using task trainers. VL competency was demonstrated after successful simulated intubations and a written test score ≥80%. Intubations were video-recorded and used to provide feedback and create content for teaching. <h3>Results</h3> Table 1 shows characteristics and Table 2 outcomes. VL did not improve first pass intubation but did increase overall intubation success. VL made intubation easier among all 7 known difficult airway cases. Adverse events occurred in 2 (2.0%). User satisfaction with VL was high as shown in Figure 1. <h3>Conclusion</h3> We did not improve first pass intubation success but did increase overall intubation success. There was high user satisfaction and rare adverse events. To increase intubation success, our next change idea is to refine our VL training and increase simulation training.

371 Emergency Physician First Pass Intubation Success Is Similar in Inpatient Settings and the Emergency Department

Emergency medicine (EM) physicians (EPs) are sometimes called to perform tracheal intubation for critically ill patients outside of the emergency department (ED), for example as part of a hospital airway or medical emergency team. Differences in patient characteristics or intubation context in the inpatient units (ie, cognitive, team-based, or environmental challenges) may be associated with changes in the safety and success of tracheal intubation, as compared to intubations performed in the ED. Our objective was to characterize intubation performance for EPs in the ED compared to inpatient settings. We hypothesized that first-pass success rates for EPs in different settings would not be significantly different. We performed a retrospective, single center study of adult patients intubated at Hennepin County Medical Center in the ED, Intensive Care Units (ICU), and inpatient units between March 2019 and April 2021. Patients intubated in these settings by a non emergency physician were excluded. Clinical data and patient variables were collected from the electronic health record (EHR). Patient demographics, first attempt success rate, and hospital mortality were captured. The primary outcome, successful intubation on the first laryngoscopy attempt across settings, was evaluated using an unadjusted chi square test. The first attempt success rate for intubations performed by emergency physicians was 95.5% (1683/1763) in the ED, 94.8% (1072/1131) in the ICU, and 94.6% (156/165) in inpatient non-ICU settings. These differences did not reach statistical significance (p=0.66 by chi square test). Mean age was 47.1 years in the ED, 50.5 years in the ICU, and 46.8 years in inpatient non-ICU settings. The most common primary diagnoses for all settings were altered mental status, cardiac arrest, and sepsis. Hospital mortality was significantly different (p < 0.001) for patients intubated by emergency physicians in the different settings, with a rate of 15% for ED patients, 20% in the ICU, and 24% in inpatient non-ICU settings. Emergency physicians achieved >94% first pass intubation success among critically ill patients regardless of hospital setting, and the rates of first pass success in the ED, ICU, and non-ICU inpatient units were similar. The first attempt success rate in this study is similar to previous ED studies, however is higher than the rate in previous descriptions in the ICU setting. This suggests that EPs perform intubations outside of the emergency department with a high level of performance. Limitations of this study include the use of EHR procedural documentation to evaluate first attempt success rate. Further research should include data collection by trained observers and in multiple institutions.

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

Comparação entre o videolaringoscópio King Vision e o laringoscópio Macintosh: um ensaio clínico prospectivo randomizado e controlado

Background and objectivesWe compared the efficiency of the King Vision video laryngoscope and the Macintosh laryngoscope, when used by experienced anesthesiologists on adult patients with varying intubating conditions, in a prospective randomized controlled clinical trial. MethodsA total of 388 patients with an American Society of Anesthesiologists physical status of I or II, scheduled for general anesthesia with endotracheal intubation. Each patient was intubated with both laryngoscopes successively, in a randomized order. Intubation success rate, time to best glottic view, time to intubation, time to ventilation, Cormack–Lehane laryngoscopy grades, and complications related to the laryngoscopy and intubation were analyzed. Results and conclusionsFirst pass intubation success rates were similar for the King Vision and the Macintosh (96.6% vs. 94.3%, respectively, p>0.05). King Vision resulted in a longer average time to glottic view (95% CI 0.5–1.4s, p<0.001), and time to intubation (95% CI 3–4.6s, p<0.001). The difference in time to intubation was similar when unsuccessful intubation attempts were excluded (95% CI 2.8–4.4s, p<0.001). Based on the modified Mallampati class at the preoperative visit, the King Vision improved the glottic view in significantly more patients (220 patients, 56.7%) compared with the Macintosh (180 patients, 46.4%) (p<0.001). None of the patients had peripheral oxygen desaturation below 94%. Experienced anesthesiologists may obtain similar rates of first pass intubation success and airway trauma with both laryngoscopes. King Vision requires longer times to visualize the glottis and to intubate the trachea, but does not cause additional desaturation.

Comparison of King Vision video laryngoscope and Macintosh laryngoscope: a prospective randomized controlled clinical trial

Background and objectivesWe compared the efficiency of the King Vision video laryngoscope and the Macintosh laryngoscope, when used by experienced anesthesiologists on adult patients with varying intubating conditions, in a prospective randomized controlled clinical trial. MethodsA total of 388 patients with an American Society of Anesthesiologists physical status of I or II, scheduled for general anesthesia with endotracheal intubation. Each patient was intubated with both laryngoscopes successively, in a randomized order. Intubation success rate, time to best glottic view, time to intubation, time to ventilation, Cormack–Lehane laryngoscopy grades, and complications related to the laryngoscopy and intubation were analyzed. Results and conclusionsFirst pass intubation success rates were similar for the King Vision and the Macintosh (96.6% vs. 94.3%, respectively, p>0.05). King Vision resulted in a longer average time to glottic view (95% CI 0.5–1.4s, p<0.001), and time to intubation (95% CI 3–4.6s, p<0.001). The difference in time to intubation was similar when unsuccessful intubation attempts were excluded (95% CI 2.8–4.4s, p<0.001). Based on the modified Mallampati class at the preoperative visit, the King Vision improved the glottic view in significantly more patients (220 patients, 56.7%) compared with the Macintosh (180 patients, 46.4%) (p<0.001). None of the patients had peripheral oxygen desaturation below 94%. Experienced anesthesiologists may obtain similar rates of first pass intubation success and airway trauma with both laryngoscopes. King Vision requires longer times to visualize the glottis and to intubate the trachea, but does not cause additional desaturation.

Comparison of intubation success and glottic visualization using King Vision and C-MAC videolaryngoscopes in patients with cervical spine injuries with cervical immobilization: A randomized clinical trial.

Background:Glottic visualization can be difficult with cervical immobilization in patients with cervical spine injury. Indirect laryngoscopes may provide better glottic visualization in these groups of patients. Hence, we compared King Vision videolaryngoscope, C-MAC videolaryngoscope for endotracheal intubation in patients with proven/suspected cervical spine injury.Methods:After standard induction of anesthesia, 135 patients were randomized into three groups: group C (conventional C-MAC videolaryngoscope), group K (King Vision videolaryngoscope), and group D (D blade C-MAC videolaryngoscope). Cervical immobilization was maintained with Manual in line stabilization with anterior part of cervical collar removed. First pass intubation success, time for intubation, and glottic visualization (Cormack – Lehane grade and percentage of glottic opening) were noted. Intubation difficulty score (IDS) was used for grading difficulty of intubation. Five-point Likert scale was used for ease of insertion of laryngoscope.Results:First attempt success rate were 100% (45/45), 93.3% (42/45), and 95.6% (43/45) in patients using conventional C-MAC, King Vision, and D blade C-MAC videolaryngoscopes, respectively. Time for intubation in seconds was significantly faster with conventional C-MAC videolaryngoscope (23.3 ± 4.7) compared to D blade C-MAC videolaryngoscope (26.7 ± 7.1), whereas conventional C-MAC and King Vision were comparable (24.9 ± 7.2). Good grade glottic visualization was obtained with all the three videolaryngoscopes.Conclusion:All the videolaryngoscopes provided good glottic visualization and first attempt success rate. Conventional C-MAC insertion was significantly easier. We conclude that all the three videolaryngoscopes can be used effectively in patients with cervical spine injury.

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation

Objectives: Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates. Methods: We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest). Results: There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41). Conclusion: Fewer patients with advanced airway management received orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill.

IntroductionRapid sequence induction (RSI) of critically ill patients outside of theatres is associated with a higher risk of hypoxia, cardiovascular collapse and death. In the prehospital and military environments, there is an increasing awareness of the benefits of standardised practice and checklists.MethodsWe conducted a non-systematic review of literature pertaining to key components of RSI preparation and management. A standard operating procedure (SOP) for in-hospital RSI was developed based on this and experience from large teaching hospital anaesthesia and critical care departments.ResultsThe SOP consists of a RSI equipment set-up sheet, pre-RSI checklist and failed airway algorithm. The SOP should improve RSI preparation, crew resource management and first pass intubation success while minimising adverse events.ConclusionBased on the presented literature, we believe the evidence is sufficient to recommend adoption of the core components in the suggested SOP. This standardised approach to RSI in the critically ill may reduce the current high incidence of adverse events and hopefully improve patient outcomes.

Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study

BackgroundIntraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and...

Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department

The objective of the study is to compare the efficacy of video laryngoscopy (VL) to direct laryngoscopy (DL) on the first pass intubation success of patients with difficult airway characteristics (DACs) in the emergency department (ED). Over a 6-year period, between July 1 2007 and June 30 2013, all intubations performed in an academic ED were recorded in a continuous quality improvement (CQI) database by the operators. The CQI form included information such as patient demographics, operator level of training, device(s) used, number of attempts and outcome of each attempt. In addition, operators performed a difficult airway assessment and noted the presence or absence of the following difficult airway characteristics (DACs): airway edema, cervical immobility, facial/neck trauma, large tongue, obesity, short neck, small mandible, and blood or vomit in the airway. Patients <18years of age and those not intubated by an emergency physician (EP) were excluded from the analysis. Multivariate regression models were developed to determine the effect of device type (VL or DL) on first pass intubation success as the number of DACs increased. A total of 2,423 intubations were included in this study. First pass success by the number of DACs was as follows in the VL and DL groups, respectively: no DACs [90.8% (95% CI 87.5-93.4) vs. 82.0% (95% CI 78.0-85.5)]; one DAC [85.1% (95% CI 81.2-88.5%) vs. 69.4% (95% CI 63.9-74.5%)]; two DACs [(80.5% (95% CI 74.7-85.6%) vs. 65.8% (95% CI 57.6-73.3%)]; three or more DACs [68.9% (95% CI 63.8-73.7%) vs. 54.1% (95% CI 46.3-61.8%)]. After adjusting for potential confounders, VL was associated with higher odds of first pass success for patients with no DACs (aOR 2.0, 95% CI 1.2-3.3), one DAC (aOR 3.2, 95% CI 1.9-5.6), two DACs (aOR 2.3, 95% CI 1.1-4.9), and three or more DACs (aOR 2.9, 95% CI 1.5-5.5). In patients with DACs, VL was associated with a higher first pass success than DL. VL is recommended as the primary intubating device for patients with predicted difficult airways in the ED.