This document summarizes data from an airway committee meeting regarding intubation outcomes at a hospital (RCH). The key points are: 1) Intubation data from 582 cases over 3 years was reviewed and complications increased significantly with more than one intubation attempt. 2) International studies also found increased complications with more than one attempt, supporting the committee's findings. 3) The committee made recommendations to improve outcomes, such as developing difficult airway protocols, checklists for intubation, and identifying difficult airway patients. 4) Future areas for improvement included more education and establishing airway experts to handle difficult cases. Standardizing equipment and procedures was also recommended.

1. Intubation Data
Collection and
Outcomes at RCH
RCH AIRWAY COMMITTEE

2. Anterior cervical discectomy and fusion to
removing a cervical herniated disc in order to
relieve spinal cord or root pressure and
alleviate corresponding pain, weakness, and
numbness

3. So What Went Wrong
-no communicated airway plan
-unidentified difficult airway
-no expert/airway competent operator
-no second operator
-no use of other adjuncts/supraglottic
devices
-no surgical airway

4. Seeing a Theme
• Improper use of airway equipment
• Discomfort with surgical airways
• No communciated plan
• No use of supraglottic airways

5. RCH Airway
Committee
•RTs
•RNs
•MDs
•Admin

6. Mandate
Leave your ego at the door
Airway Incidents
Equipment
Protocols
Education and Research

7. Components
1. Data gathering and review
a. Data gathering forms
b. Data gathered to date
2. Introduction of improvements;
a. Difficult airway bands/signs
b. Difficult airway forms
c. Pre- intubation checklist/ Emergent Intubation PPO
d. Difficult airway protocol dissemination/education
3. Future plans
1. Extubation protocol
2. Educate FHA

8. Endotracheal Intubation
Who
Where
How
Why

11. Challenges
Missing Data Points!!!
Capture Rate?

12. RCT ETI data July 5TH
2012 to November
2nd 2015
582 total documented intubations

13. Times of the day to Intubate
0001-0600
0601-1200
1201-1800
1801-2400

14. Of the total 535 documented
PGY
Fellows
Eps
Critical Care
Anaesthesia
No data
RT

15. LOCATIONS
ER
ICU
WARDS
CSICU
CATH LAB
HAU
PACU
IR/MED IMAGING
NO DATA

16. INDICATIONS
RESP FAIL
DEC LOC
SHOCK
OTHER
NO DATA

17. ETI URGENCY
EMERGENT
URGENT
ELECTIVE
NO DATA

18. PRE OXYGENATION
BMV
BMV WITH PEEP
BMV WITH APNEIC OXYGENATION
FM
NIV
NOT DONE

19. BMV CLASS
EASY
ORAL A/W
2 HANDS/2 OPERATORS
IMPOSSIBLE
NOT DONE
NO DATA

20. INCIDENCE
RCH ICU and ED: Difficult BVM 38/189=20%
Kheterpal (2009) Difficult BVM 2.2% Impossible BVM 0.15%

21. • 4 year observational study
• N=53,041
• 77 cases of impossible mask ventilation
• Only 19 of these were difficult a/w

22. • 183 events of no verbal plan/ airway strategy/ airway
assessment

23. GRADE
ONE
TWO
THREE
FOUR
NO DATA

24. TECHNIQUES
MACINTOSH
GLIDESCOPE
BOUGIE
FIBEROPTIC
KING VISION
CRIC
NO DATA

25. ATTEMPTS
• TOTAL = 776 ATTEMPTS AT ETI
• AVG ATTEMPTS AT ETI = 1.40
• MOST ATTEMPTS = 7

26. TOTAL TIME TO INTUBATE
• 1890.8 MINUTES (547 DOCUMENTED)
• LONGEST = 60 MIN
• MEAN = 3 MIN 46 SEC MEDIAN = 2MIN
0
20
40
60
80
100
120
140
160
180
0 10 20 30 40 50 60 70

27. ATTEMPT NUMBER ETI WAS
SUCCESSFUL
0
50
100
150
200
250
300
350
400
ONE TWO THREE FOUR FIVE SIX

28. Intubation success based on attempts
INTUBATION
ATTEMPTS
PATIENT
S
SUCCESS
OUT OF 338
% OF TOTAL
INTUBATIONS % SUCCESSFUL
1 224 224/338 66% 66%
2 77 77/114 23% 68%
3 22 22/37 7% 59%
4 4 4/15 1.2% 27%
5 0 0/327 0% 0%
6 4 4/11 1.1% 36%
FAILED 1 <1% N/A
NO
DOCUMENTATIO
N 6 2% N/A

29. Complications
Severe:
•SBP <70mmHg if >90 mmHg
•O2 Sat’n <80% if >90%
•Esophageal intubation
Other: aspiration, dental trauma,
endobronchial intubation, pneumothorax
Cardiac Arrest or Death

30. A/W ASSESSMENT: 105 CASES OF NO COMMUNICATION
AND/OR DIFF A/W DISCUSSION.
July 2012 to May 2013
Verbal plan
complications
Complication 1 attempt n= 148 >1 attempt n = 71 %
Severe 9 19 6% vs 27%
All other complications 2 4 1.3% vs 5.6%
Non Verbal plan
complications
Complication 1 attempt n= 33 >1 attempt n = 19 %
Severe 3 6 9% vs 32%
All other complications 2 9 6% vs 47%

31. Our Abstracts
1 Attempt (n =224 ) >1 Attempt (n=108)
%
All Complications 20 44
8.9% vs 41%
Severe Complications 18 32
8.0% vs 30%
1. Any Complication: Aspiration, dental trauma, endobronchial intubation, pneumothorax
or any severe complication
2. Severe Complication:
- Hypotension: Systolic blood pressure <70mmHg if >90mmHg prior to attempt
- Hypoxia: oxygen saturation <80% if >90% prior to attempt
- Esophageal intubation

32. Authors
Absolute
Risk of Adverse
Event
Griesdale 2008
n=136
18% 38%
Sackles 2013
n=1828
14% 53%
RCH Data
n=332
8% 41%
Complications Increase with >1 Attempt

33. 1Attempt ≥3 Attempts

34. Conclusions
• Greater than one attempt at ETI was associated
with a 4-fold increase in severe, and a 5-fold
increase in total complications.
• Although previous publications found greater
than 2 attempts associated with increased
complications1,2, recent publications found this
association with greater than one attempt3,4,
consistent with our findings. This new
information has implications for both teaching
and decision-making of ETI.

35. Complications: Absolute Risk
**

38. Future questions
• Total Complications vs. number of attempts sorted by staff
vs. resident
• Complication Type by Attempt Number
• First Attempt Success Rate (Staff MD vs resident)
• How many times did the Doc think it took to intubate vs the
RT
• Did having a checklist decrease the overall complications

39. Difficult Airway Labeling
• Who?
• Patient’s who have a difficult airway as defined by the
intubator
• Why?
• To provide visual cues to intubators that this may be/was
a difficult intubation.
• This allows early request for additional aid and
equipment.
• How?
• Airway alert bracelets
• Airway alert signs at the head of the patients bed

45. • When first attempt DL unsuccessful, repeated DL 80% failure rate.
• Recommend identification and detailing difficult A/W details

46. • Previous difficult intubation (DTI) 6 times more likely to be DTI again
• Previous failed intubation 22 times more likely to fail again.
• As a result of findings Denmark created database

47. • N=649,359
• Favourable Neurological outcome;
• Intubation UGLY
• SGA Worse
• BVM BEST

48. • 57 successful intubations to have 90% success rate
• Still improving into the 80s
• certification programs for RTs use the number 5-10
intubations to be certified. On this learning curve that
would put them at 40% mean success rate

49. Thebiggeststudyofairwaysever
accomplished
307 Hospitals
4 Countries
1 year
Prospective
ICU, ED, OR
Airway Cases:
Death
Brain Damage
Unexpected ICU

50. NAP 4
• 4 Common themes identified
• 1) Lack of airway assessment
• 2) Lack of airway strategy
• 3) Avoidance of awake techniques
• 4) The failure to plan for Failure: repeated attempts using the
same people/equipment

51. NAP 4
• 98/133 no documented airway exam
• 66 ‘may be difficult’-1 change in airway strategy
• needle Cricothyrotomy: 64% (16/25) Failure
Rate
• Failure to use capnography implicated in 82% of
ICU airway deaths and brain damage

52. NAP4 Reccommendations
• Develop a checklist for intubation
• Standardize Difficult A/W equipment
• Including SGA and Aintree catheters
• Do more awake FOB intubations
• Investigate A/W critical incidents
• Appoint an A/W lead anesthetist in all institutions.
• Capnography is mandatory

53. NAP4 Reccomendations
• Identify Difficult A/W patients
• Establish good communication between ICU, ER, and
Anesthesia
• Establish clear lines of communication to escalate A/W events
to individuals with appropriate skills.

54. What we have done
• 24 hour a day response from a rover
Anesthesiologist for difficult airways
• Empowered any member of team to escalate
airway emergencies

55. • ETCO2 monitoring at every intubation
• Standardize difficult intubation equipment
• Standardize intubation procedure
• Preprinted orders

56. Other actions:
Airway Exchange Catheter, Cook Medical

57. What’s Next
• Define Airway expert
• Define Airway competency
• Education

58. So…. Should RTs be intubating?
• We often don’t do enough intubations to maintain
competency
• Dealing with failed A/W is beyond our scope
• Greater than one attempt significantly increases severe
complications

59. Lessons
• People with more experience have better success
• “Emphasis should be placed on effective ventilation and
oxygenation using BVM”