Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest

Resuscitation. 2021 Oct:167:289-296. doi: 10.1016/j.resuscitation.2021.07.001. Epub 2021 Jul 14.


Background: International guidelines emphasize advanced airway management during out-of-hospital cardiac arrest (OHCA). We hypothesized that increasing endotracheal intubation attempts during OHCA were associated with a lower likelihood of favorable neurologic survival at discharge.

Methods: This retrospective, observational cohort evaluated the relationship between number of intubation attempts and favorable neurologic survival among non-traumatic OHCA patients receiving cardiopulmonary resuscitation (CPR) from January 1, 2015-June 30, 2019 in a large urban emergency medical services (EMS) system. Favorable neurologic status at hospital discharge was defined as a Cerebral Performance Category score of 1 or 2. Multivariable logistic regression, adjusted for age, sex, witness status, bystander CPR, initial rhythm, and time of EMS arrival, was performed using the number of attempts as a continuous variable.

Results: Over 54 months, 1205 patients were included. Intubation attempts per case were 1 = 757(63%), 2 = 279(23%), 3 = 116(10%), ≥4 = 49(4%), and missing/unknown in 4(<1%). The mean (SD) time interval from paramedic arrival to intubation increased with the number of attempts: 1 = 4.9(2.4) min, 2 = 8.0(2.9) min, 3 = 10.9(3.3) min, and ≥4 = 15.5(4.4) min. Final advanced airway techniques employed were endotracheal intubation (97%), supraglottic devices (3%), and cricothyrotomy (<1%). Favorable neurologic outcome declined with each additional attempt: 11% with 1 attempt, 4% with 2 attempts, 3% with 3 attempts, and 2% with 4 or more attempts (AOR = 0.41, 95% CI 0.25-0.68).

Conclusions: Increasing number of intubation attempts during OHCA resuscitation was associated with lower likelihood of favorable neurologic outcome.

Keywords: Airway management; Cardiopulmonary resuscitation; Emergency medical services; Emergency medical technicians; Heart arrest; Intratracheal; Intubation.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cardiopulmonary Resuscitation*
  • Emergency Medical Services*
  • Humans
  • Intubation, Intratracheal
  • Out-of-Hospital Cardiac Arrest* / therapy
  • Retrospective Studies