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Airway management can involve unanticipated complications leading to severe consequences. Emergency department (ED) and intensive care unit (ICU) physicians are all too familiar with potential complications, including oesophageal intubation, pulmonary aspiration, and failed airway management requiring rescue maneuvers. Although major airway management-related complications are rare, they can be amongst the most life-threatening in medicine.
While ED doctors understand the importance of successful intubations and often aim to master the concept of first pass success, the truth is first intubation attempts often fail. Studies suggest that 17 to 29 percent of all ED intubations take two or more attempts.
Before exploring why avoiding failed intubation attempts is paramount to successful airway management, let's define two important terms to better understand the context.
Failed tracheal intubation means the doctor could not achieve successful tracheal intubation, regardless of the technique used.
First rescue intubation takes place after the initial failed attempt(s) by a different intubator or with different devices and/or methods. For instance, when the intubation does not succeed with a sedative, the second attempt may be with RSI. In this scenario, the second intubation is considered the "first rescue intubation."
It is widely accepted that repeated tracheal intubation can have devastating consequences. Multiple failed attempts increase the risk of airway obstruction, which may lead to severe airway complications. The high incidence of adverse outcomes explains why major guidelines recommend physicians refrain from repeated attempts at endotracheal intubations.
Studies have shown that multiple failed intubation attempts are associated with a decreased success rate on the first rescue intubation in the ED. That means the more failed attempts doctors make to intubate their patients using one particular intubation method, the less likely it will be for the rescue intubation to work the first time.
There are multiple possible reasons for these findings. First, direct airway trauma is not an uncommon result of failed intubation attempts. Trauma makes it challenging for the physician to visualize the airway, making the rescue method more likely to fail. Second, when a skilled doctor does not succeed even after multiple tries, it becomes more likely that the physician is dealing with an unanticipated difficult airway.
The scientific literature has also confirmed that repeated intubation attempts increase the risk of adverse events, including cardiac arrest, arrhythmia, regurgitation, and airway trauma. Therefore, identifying potential difficult intubation cases early on can help prepare for the appropriate management of complex airways.
Physicians who perform tracheal intubation in critically ill patients must take special care to avoid failed intubation attempts and strive for first attempt success. In these patients, repeated attempts lead to an increased risk of complications and adverse patient outcomes. Hypoxemia and hemodynamic deterioration are common complications that should be avoided.
It is easy to see that intubation-associated adverse event rates rise with the increased number of intubation attempts. This is why it is wise to seek out airway management solutions that are easy to use, help improve first attempt success rates and ultimately advance patient outcomes.
Avoiding failed tracheal intubation attempts is essential to ensure the best possible results. Besides training, airway management expertise, skills to use multiple techniques, assessment, teamwork, and planning, innovative solutions can help improve first-pass success rates.
As most difficult airways are unanticipated, tapping into medical device innovation to safely navigate difficult airways can be an absolute game-changer. QuickSteer™ allows physicians to quickly and effectively intubate patients with even the most complex airways. Thanks to the shorter time to place the tip of the intubation aid through the vocal cords, QuickSteer™ helps improve overall intubation time and patient safety while reducing failed intubation attempts.
Watch this video to see QuickSteer™ in action.
Want to learn more? Connect with a specialist by calling 763.330.2162 or emailing info@accessairways.com.
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References:
https://sjtrem.biomedcentral.com/articles/10.1186/s13049-014-0085-8
https://academic.oup.com/bja/article/109/suppl_1/i68/293543
https://pubs.asahq.org/anesthesiology/article/125/4/615/19643/Avoiding-Repeated-Attempts-at-Tracheal
