Factors associated with tracheal intubation–related complications in the prehospital setting: a prospective multicentric cohort study

Abstract

Background Emergency tracheal intubation is routinely performed in the prehospital setting. Airway management in the prehospital setting has substantial challenges. Objective The aim of the present study was to determine risk factors predicting tracheal intubation–related complications on the prehospital field. Setting A prospective, multicentric, cohort study which was conducted in three mobile ICUs (MICUs; service mobile d’urgence et de réanimation).Outcome measures and analysis Tracheal intubation–related complications were defined as the occurrence of at least one of the following events: oxygen desaturation (SpO2 < 90%) during tracheal intubation, aspiration (regurgitation visualized during laryngoscopy), and vomiting. Difficult intubation was defined as more than two failed direct laryngoscopic attempts, or the need for any alternative tracheal intubation method. Multivariate logistic regressions were used. Results During the 5-year study period, 1915 consecutive patients were intubated in the MICUs participating in the study. Overall, 1287 (70%) patients were successfully intubated after the first laryngoscopic attempt, with rates of 90, 74, 42, and 30% for Cormack–Lehane grade 1, 2, 3, and 4, respectively. Tracheal intubation was difficult in 663 cases (36%). Tracheal intubation–related complications occurred in 267 (14%) patients. In the multivariate analysis, we found that the leading risk factors for tracheal intubation–related complications were Cormack and Lehane grade 3 and 4 [odds ratio (OR) = 1.65; 95% confidence interval (CI), 1.05–2.61; and OR = 2.79; 95% CI, 1.56–4.98, respectively], a BMI of more than 30 (OR = 1.61; 95% CI, 1.13–2.28), when intubation was difficult (OR = 1.72; 95% CI, 1.15–2.57), and when tracheal intubation required more than one operator (OR = 2.30; 95% CI, 1.50–3.49).Conclusions In this prospective study, we found that Cormack and Lehane more than grade 2, BMI >30, difficult intubation, and tracheal intubation requiring more than one operator were all independent predictors of tracheal intubation–related complications in the prehospital setting. When these risk factors are identified on scene, adapted algorithms that anticipate the use of a bougie should be generalized to reduce morbidity on the prehospital field.

Training approaches and devices utilization during endotracheal intubation in French Emergency Departments: a nationwide survey

“…Most participating centers in the survey were equipped with these devices and routinely used them during intubation in the ED. However, any lack of systematic use of capnography for ETI remains surprising, as failure to use capnography contributes to 74% of death or persistent neurological injury [29][30][31]. Limited data exist to clarify this discrepancy between the guidelines' endorsement, device availability, and consistent application.…”

“…These complications are mostly attributed to recurring gaps in care, such as inadequate detection of patients who are at risk, ineffective planning strategies, a shortage of skilled staff and necessary equipment to manage such situations effectively, and failed rescue attempts caused either by an absence of capnography [16,29]. Therefore, difficult intubation, ranging from 4.7% in the INTUBE study [16] to 14% in recent pre-hospital settings [30], requires constant training with different available equipment [31]. Dedicated guidelines highlight the importance of the recognition and declaration of difficult airways, detailed planning and preparation, adequate staffing, positioning, preoxygenation and availability of necessary equipment during any airway management procedure [4,32].…”

Detecting cervical esophagus with ultrasound on healthy voluntaries: learning curve

“…The main causes of emergency recourse to orotracheal intubation are cardiac arrest (44%), neurological distress (16%), and toxic coma (15%) [ 1 ]. In prehospital settings, the rate of esophageal intubation is as high as 30% after the first attempt [ 2 , 3 ], increasing the risk of gastric distension and regurgitation [ 4 , 5 ]. If not quickly identified, the main complication is hypoxia potentially leading to cardiac arrest (CA) and to the patient’s death, or at least inducing severe neurological sequelae [ 6 ].…”