Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit

Raj Joshi, Cameron D. Hypes, Jeremy Greenberg, Linda S Snyder, Josh Malo, John W Bloom, Harsharon Chopra, John C. Sakles, Jarrod M. Mosier

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICUwith a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. Conclusions: In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

Original languageEnglish (US)
Pages (from-to)368-375
Number of pages8
JournalAnnals of the American Thoracic Society
Volume14
Issue number3
DOIs
StatePublished - Mar 1 2017

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Laryngoscopy
Intubation
Intensive Care Units
Confidence Intervals
Odds Ratio
Edema
Obesity
Logistic Models
Laryngoscopes
Equipment and Supplies
Tongue
Critical Illness
Sex Characteristics
Observational Studies
Mouth
Regression Analysis
Databases

Keywords

  • Critical care
  • Difficult intubation
  • Intubation
  • Video laryngoscopy

ASJC Scopus subject areas

  • Medicine(all)
  • Pulmonary and Respiratory Medicine

Cite this

Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit. / Joshi, Raj; Hypes, Cameron D.; Greenberg, Jeremy; Snyder, Linda S; Malo, Josh; Bloom, John W; Chopra, Harsharon; Sakles, John C.; Mosier, Jarrod M.

In: Annals of the American Thoracic Society, Vol. 14, No. 3, 01.03.2017, p. 368-375.

Research output: Contribution to journalArticle

Joshi, Raj ; Hypes, Cameron D. ; Greenberg, Jeremy ; Snyder, Linda S ; Malo, Josh ; Bloom, John W ; Chopra, Harsharon ; Sakles, John C. ; Mosier, Jarrod M. / Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit. In: Annals of the American Thoracic Society. 2017 ; Vol. 14, No. 3. pp. 368-375.
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abstract = "Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICUwith a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9{\%}; 95{\%} confidence interval [CI], 20.7-27.0{\%} vs. 13.3{\%}; 95{\%} CI, 8.0-18.8{\%}). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95{\%} CI, 1.64-4.20), airway edema (OR, 2.85; 95{\%} CI, 1.48-5.45), and obesity (OR, 1.59; 95{\%} CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95{\%} CI, 1.60-4.64), cervical immobility (OR, 3.34; 95{\%} CI, 1.28-8.72), and airway edema (OR, 3.10; 95{\%} CI, 1.42-6.70) were associated with first-attempt failure. Conclusions: In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.",
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AU - Joshi, Raj

AU - Hypes, Cameron D.

AU - Greenberg, Jeremy

AU - Snyder, Linda S

AU - Malo, Josh

AU - Bloom, John W

AU - Chopra, Harsharon

AU - Sakles, John C.

AU - Mosier, Jarrod M.

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N2 - Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICUwith a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. Conclusions: In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

AB - Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICUwith a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. Conclusions: In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

KW - Critical care

KW - Difficult intubation

KW - Intubation

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