Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts

TLDR

Repeated conventional tracheal intubation attempts can increase patient morbidity. The study analyzed 2,833 critically ill patients in an emergency intubation database, assessing airway and hemodynamic complications relative to the number of laryngoscopic attempts. More than two laryngoscopic attempts markedly raised airway and hemodynamic complications—hypoxemia rose from 11.8% to 70%, regurgitation from 1.9% to 22%, aspiration from 0.8% to 13%, bradycardia from 1.6% to 21%, and cardiac arrest from 0.7% to 11%—supporting a limit of three attempts.

Abstract

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (</=2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.