How Important is First Attempt Success in Airway Management?

October 29, 2024

Written by Aaron Lacy

Spoon Feed 
In this NEAR database study, there was an independent association between increasing number of intubation attempts and risk of complications.

No attempts, no problems 
In this NEAR database review of 15,079 intubations, 70% were done with video laryngoscopy and 91% were done by residents. An attempt was counted each time the leading edge of the laryngoscope blade entered the oral cavity past the alveolar ridge. In multivariable logistic regression the authors found the odds ratios (95%CI) of a major airway complication relative to first attempt success were 4.4 (3.6-5.3), 7.4 (5.0-10.7), 13.9 (5.6-34.3), and 9.3 (2.1-41.7) for attempts 2-5+, respectively.

How will this change my practice? 
For years research has often utilized first attempt success as an important outcome in airway management research. This has not been without controversy, with some saying that first attempt success is not a patient centered outcome, while others claim it is a good surrogate for adverse events.

How does this change what I do? On shift, it doesn’t – I still prioritize securing the airway on the first attempt. From a scholarly and research standpoint, this large dataset review helps first attempt success retain its position as a juggernaut of outcome variables in airway research.

As we move forward as an airway research community, I still think there is room for a more stringent definition of first attempt success (one blade insertion and one tube/introducer insertion), especially given increasing recognition that glottic visualization is only part of a smooth and successful intubation attempt – the tube has to make it through the cords too!

Source 
Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study. AJEM. 2024. Sep 11;85:202-207. DOI: 10.1016/j.ajem.2024.09.014. PMID: 39288499