Cumulative Success of Prehospital Advanced Airway Management in a National Cohort

Introduction—Repeated attempts at advanced airway management are associated with increased risk of adverse events. There are few current descriptions of the number of attempts needed for success. This study sought to characterize cumulative advanced airway management success rates in a national cohort of EMS agencies.

Methods—The study used 9 years of data from ESO Solutions, a national EMS electronic health record system. An inclusion criterion was encounters with attempted advanced airway management. The following subsets were studied: 1) cardiac arrest intubation (CA-ETI); 2) medical nonarrest intubation (NA-ETI); 3) rapid-sequence intubation (RSI); 4) sedation-assisted ETI (SAI); and 5) some type of supraglottic airway (SGA). Using binomial proportions with exact confidence intervals, researchers determined the cumulative success rates for each attempt along with identified rates of first-pass success (FPS) and overall success (OS), and the number of attempts needed to reach OS.

Results—At total of 61,793 patients from 552 EMS agencies underwent advanced airway management efforts, including 38,063 CA-ETI; 19,138 NA-ETI; 7,229 RSI; 3,095 SAI; and 9,993 SGA. The number of advanced airway management attempts per patient varied (median 1, range 1–10). CA-ETI performance was: FPS 71.4% (95% CI: 70.8%–71.9%), with four attempts to reach the OS threshold of 91.7% (91.4%–92.1%). NA-ETI performance was: FPS 66.3% (95% CI: 65.4%–67.2%), with three attempts to reach the OS threshold of 80.4% (79.6%–81.1%). RSI performance was: FPS 75.9% (95% CI: 74.9%–76.9%), with five attempts to reach the OS threshold of 96.3% (95.8%–96.7%). SAI performance was: FPS 66.9% (95% CI: 65.2%–68.6%), with four attempts to reach the OS threshold of 86.9% (85.6%–88.1%). SGA performance was: FPS 88.8% (95% CI: 88.1%–89.4%), with five attempts to reach the OS threshold of 93.2% (92.6%–93.6%).

Conclusion—In this national series, first-pass prehospital advanced airway management success rates have improved from earlier studies but are still low. Multiple attempts are common and often unsuccessful. These results may guide protocols limiting advanced airway management attempts.