Description of Critical Care Transport First Pass Endotracheal Intubation Failures

Objective

Describe first pass endotracheal intubation failures as well as associated patient and procedural factors in a rural critical care transport service.

Methods

Retrospective chart review of patients ≥18 years intubated by a mixed rotor wing and ground critical care transport service (nurse-paramedic teams) between January 2017 and June 2024. Direct and video laryngoscopy was available during the study period. The primary outcome was incidence of first pass failure. One intubation attempt was defined as the insertion of the laryngoscopy past the lips. First pass failure was defined as failure to place an endotracheal tube through the vocal cords on the first intubation attempt. Secondary outcomes included reason for failure as well as association of patient and procedural factors with failure.

Results

There were 389 intubations performed with 53 (13.6%) first pass failures. The most common reasons for failure were hypoxia (7, 13.2%), contamination (22, 41.5%), and anatomy (32, 60.4%). Multiple reasons for failure were cited in 15 first pass intubation attempts (28.3%). There was an association between first pass failure and predicted difficult airway OR 2.66 (95% CI 1.47-4.80). There was no association between operator type and first pass success rate. There was no association of first pass failure with bougie use, direct laryngoscopy, location of intubation, or pre-intubation hypoxia.

Conclusion

First pass failure occurred in approximately one in eight intubations. This descriptive analysis of intubation failure provides a starting point for further quality improvement work. Future work should incorporate systematic review of intubations with objective data (i.e. video-recorded laryngoscopy) and the use of an airway failure taxonomy to describe performance errors and allow for iterative quality improvement in a learning healthcare system.