Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments

OBJECTIVE

The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success.

METHODS

Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres.

RESULTS

Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21).

CONCLUSIONS

The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.

Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates

OBJECTIVE

To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU).

DESIGN

Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates.

SETTING

Ten academic NICUs.

PATIENTS

Neonates intubated in the NICU at each of the sites between October 2014 and March 2017.

MAIN OUTCOME MEASURES

Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation.

RESULTS

Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53).

CONCLUSIONS

Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.