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How Many Intubations Does It Take For Proficiency?

October 18, 2018

Written by Clay Smith

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It is estimated that to place an endotracheal tube (ETT) successfully during CPR in 30-60 seconds using direct laryngoscopy would take 3-5 years of experience and 137-243 endotracheal intubations (ETI).  Increased experience did not reduce the time chest compressions were paused.  The key take-home is that ETI during CPR is really hard.  Be prepared.

Why does this matter?
It takes a median 47 ETI in a controlled OR setting to achieve 90% success.  But it is much more difficult during CPR.  How many ETI does it take to gain the skill to quickly place an ETT during CPR?

It’s not easy
This was a video review of 110 cases with CPR for non-traumatic arrest and ETI using direct laryngoscopy (not video).  Emergency medicine trainees in Korea with varying levels of experience were observed using retrospective video footage and timed on how long it took to place the ETT and how long the pause in compressions was.  They took this data and extrapolated that it would take 137 intubations and 3.3 years of experience to place 90% of ETTs during CPR in under 60 seconds.  It would take 243 intubations and 5.4 years of experience to achieve 90% success in ETT placement during CPR in under 30 seconds.  There was no improvement with increased provider experience in chest compression pause time.  This was a relatively small, single-center, retrospective video review, so these numbers should be taken with a healthy skepticism.  For me, the precise numbers are less important than the reality that ETT placement during CPR is really difficult and probably should not be done by providers with less experience at ETI.  When it is attempted, be prepared and give yourself every advantage, such as using video laryngoscopy, having suction handy, using external laryngeal manipulation, and a bougie.

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation?  Resuscitation. 2018 Aug 30. pii: S0300-9572(18)30829-3. doi: 10.1016/j.resuscitation.2018.08.032. [Epub ahead of print]

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