Maximizing First-Attempt Success

Brian E. Driver

Robert F. Reardon

INTRODUCTION

Achieving first-attempt intubation success is crucial for critically ill patients undergoing intubation. Failure to intubate successfully on the first attempt is associated with increased risk of hypoxemia, aspiration, cardiac arrest, and other peri-intubation complications. Reported first-attempt success rates in intensive care units (ICUs) in the United States are 65% to 82%. There are at least 1.5 million critically ill adult patients intubated annually in the United States, and 75% of first-attempt success translates to approximately 375,000 patients requiring multiple attempts before successful intubation. Since there is an adverse event rate of 60% to 70% when the first-attempt fails in the ICU setting, there is clearly room for improvement.

A large meta-analysis, published in 2017, including ED studies published from 2000 to 2016 from all over the world, demonstrated an average first-attempt success rate of 84.1%.¹ However, contemporary data from ED registries shows an average first-attempt success rate of about 90%, with success within sites participating in the ED registry vary from 77% to 97%.²^,³ First-attempt intubation success in ICUs, with a different patient population, has varied from about 70%⁴^,⁵ to 80%.⁶^,⁷ Preparation, proper patient assessment, use of checklists and algorithms, and use of modern techniques and equipment have allowed some ICUs to achieve much higher first-attempt success rates than others. This suggests that intubation success hinges more heavily on systems rather than individual skill.

Multiple studies across diverse geographic areas, medical specialties, hospital units (ED and ICU), and patient populations have shown that first-attempt success is associated with a decreased risk of hypoxemia, aspiration, cardiac arrest, and other peri-intubation complications.¹^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²

KEYS TO OPTIMIZING FIRST-ATTEMPT INTUBATION SUCCESS AND SAFETY

Optimizing first-attempt intubation success requires consistently using the best practices for all facets of intubation. Success does not occur by chance or by recruiting residents, fellows, or staff with unusually good hand-eye coordination. High success occurs by paying meticulous attention to the entire process of intubation. Elements with the greatest effect on first-attempt intubation success and patient safety include:

A standardized approach to all intubations
Appropriate use of rapid sequence intubation
Following a checklist to meticulously prepare for intubation
Robust preoxygenation
Using the best device, technique, and adjuncts
Algorithmic decision making
Early use of well-practiced rescue tools
Taking ownership with continuous quality improvement (CQI) by an airway lead

Use a Standardized Approach to Intubation

This may be the most important element affecting first-attempt intubation success and the safety of tracheal intubation of critically ill patients. Tracheal intubation is a complex process and there is still debate about which equipment and techniques are best—however, each department should decide on and standardize best practices for their group. Tracheal intubation is often a stressful event and involves multiple team members. A consistent approach leads to better teamwork, less stress, and fewer mistakes.

Departments should adopt an approach to intubation that standardizes intubation preparation, medications, techniques, and devices for nearly all patients who require intubation. The standard approach should use the best available techniques and equipment—this will ensure that the standard approach will be successful for difficult cases. Using new, unfamiliar, or rarely used techniques or devices for difficult airways will often translate to unanticipated challenges or intubation failure.

Randomized trials in the ICU and ED have studied singular elements of the intubation process including: using a checklist versus no checklist; using a direct versus video laryngoscope; placing the patient in a sniffing versus ramped position; and use of apneic oxygenation versus no apneic oxygenation. Trial results have commonly shown no difference between study groups. These trials all have limitations (e.g., studying only novice operators), and rather than demonstrating the futility of checklists, video laryngoscopes, intubation position, and the use of apneic oxygenation, they demonstrate that altering just one element in a complex process may not alter outcomes.

Tracheal intubation in critically ill patients is complex and all elements of the procedure, before, during, and after tube placement, contribute to patient safety. For instance, using a checklist will not help if the patient is not positioned properly; positioning the patient will not help if a direct laryngoscope is used for a difficult airway; and using a video laryngoscope might not help if preoxygenation is inadequate, thereby truncating laryngoscopy time. Departments and clinicians must pay particular attention to all elements of intubation, sometimes termed the process of intubation, or the airway bundle. Several key elements in the intubation process have shown improved outcomes:

Use of a preintubation checklist¹³^,¹⁴^,¹⁵
Optimization of preoxygenation and apneic oxygenation¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷
Increased use of videolaryngoscopy with standard geometry (Macintosh) blades—which allow both direct laryngoscopy and video laryngoscopy simultaneously¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁸
Increased use of a bougie or stylet¹³^,¹⁴
Decreased incidence of novices attempting emergency intubation.¹⁴^,¹⁵

When a clinician—or entire department—uses a standard airway bundle that uses the best of all available techniques and equipment, this greatly simplifies the complexity of the procedure and delivers the best care to the patient. The following sections detail some practices that might be incorporated into a department’s standard intubation approach.

The Importance of Neuromuscular Blockade for Tracheal Intubation

Perhaps nothing aids more in first-attempt intubation success than neuromuscular blockade. Before the introduction of rapid sequence intubation (RSI), intubation was significantly more difficult, and first-attempt success was uncommon.

Because of the powerful human instinct to protect the airway, placement of the laryngoscope and tube without paralysis often results in a physical struggle, poor intubating conditions, and trauma to the airway. RSI is now the standard of care for tracheal intubation of critically ill patients. Multiple prospective studies and registry data confirm the high success rate of RSI with neuromuscular blocking agents when performed by experienced operators in both adult and pediatric patients. Paradoxically, the belief that using sedatives alone without neuromuscular blockade was safer often caused more harm. Significant sedation is required to facilitate laryngoscopy and oral intubation, which commonly results in hypoventilation or apnea. Instrumenting the airway in this state can also cause vomiting, which can be disastrous in a patient without intact airway reflexes.

Appropriate Use of Rapid Sequence Intubation

RSI has revolutionized emergency airway management and is clearly associated with improved intubation success and safety. In ED intubation registries a neuromuscular blocking agent is used in approximately 85% of all ED airway encounters and in >95% of patients when those with cardiac arrest are excluded. This very high rate demonstrates that RSI should be the default method to facilitate intubation unless there is a compelling reason to select a method that will maintain spontaneous breathing (i.e., significant anatomic or physiologic difficulty—see Chapter 9, Developing your strategy)—not the other way around.

When clinicians are confident in the airway plan and backup devices and are using the best equipment, they will have confidence in the success of the procedure and the success of rescue oxygenation, which will allow use of RSI.

Use Awake Intubation When Both RSI and Rescue Oxygenation Are Likely to Fail

RSI should be avoided when intubation, rescue oxygenation, or both are deemed very difficult or potentially impossible. Less than 5% of patients will meet these criteria. The principles in Chapters 5 to 8 provide an excellent framework for assessing the difficult airway. Chapter 9 outlines the algorithmic application of this knowledge to help construct the appropriate strategy, while Chapters 10 and 11 describe how ultrasound can augment the assessment if more information is needed. The clinician must understand the importance of the decision branch point between RSI and awake intubation and not overutilize awake techniques. However, clinicians should not be cavalier in their approach to patients with difficult airway characteristics. When modern equipment and techniques are used it is rare that a patient cannot be intubated or reoxygenated, however, these cases still exist and therefore, awake intubation remains a valuable tool.

The decision to use an awake technique cannot solely rely on mnemonics and individual difficult airway markers (since at least one marker is present in 60% of intubations for critically ill patients) and must instead rely on the judgment of the clinician when considering patient characteristics, available equipment, and their level of skill and experience. In addition, there are times when awake intubation is being considered but may not be the most practical approach, including: rapidly progressing upper airway obstruction with no time for patient preparation (see Chapter 9, Developing your strategy), or a trauma patient with penetrating neck wound and copious oropharyngeal bleeding. These patients often fit in the “forced to RSI” category when developing a strategy.

If RSI is avoided, the patient should ideally be kept fully or nearly fully awake and intubation should be performed after meticulous application of topical anesthesia (Chapters 16, Topical anesthetics and anesthesia for awake intubation and 25, Flexible endoscopic intubation). If awake intubation is not possible because of lack of patient cooperation, even after liberal topical anesthesia, very small amounts of sedative agents, given serially, can be administered. The goal is not to make the patient obtunded or unconscious but to achieve the minimum level of sedation that facilitates patient tolerance and cooperation with the procedure. When significant sedation is given without neuromuscular blockade, respirations and protective airway reflexes are compromised but laryngoscopy remains challenging due to the patient’s intrinsic resistance to laryngoscope insertion and laryngeal manipulation. This can lead to airway trauma, poor glottic views, and vomiting with aspiration. All efforts should be made to make the procedure tolerable yet preserve breathing and airway reflexes until the tube is in the trachea. RSI medications and backup equipment should be readied when performing an awake intubation.

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