The Association Between Out-of-Hospital Drug-Assisted Airway Management Approach and Intubation First-Pass Success

Abstract

Study objective: Achieving first-pass success during endotracheal intubation has been identified as an area for emergency medical services improvement efforts. Evidence on the effect of out-of-hospital drug-assisted airway management, including rapid sequence intubation, sedation-only intubation, and paralytic-only intubation on first-pass success, is limited. Our objective was to determine the association between out-of-hospital drug-assisted airway management approach and first-pass success, without evaluating the appropriateness of the procedure or the association with complications.

Methods: Using a large national emergency medical services data set, we performed an observational analysis of patients treated during a 911 response who underwent at least one intubation attempt. We excluded patients who experienced cardiac arrest at any time. We then categorized drug-assisted airway management approach according to the medications they received before the initial endotracheal intubation attempt. We characterized the data set with descriptive statistics and calculated adjusted odds ratios with 95% confidence intervals to assess the association between drug-assisted airway management approach and first-pass success.

Results: We identified 12,713 patients intubated who were not in cardiac arrest. As many as 7,396 (58.4%) were male patients and 3,081 (24.2%) were intubated for traumatic conditions. The median age was 60 (interquartile range 40 to 73) years and 42.6% patients were intubated with a video laryngoscope. Drug-assisted airway management approaches included rapid sequence intubation (51.2%), no medications (29.6%), sedation-only intubation (17.9%), and paralytic-only intubation (1.3%). Overall, first-pass success was 75.1%. Compared with no medication, the adjusted odds ratios (95% confidence interval) for achieving first-pass success were higher for rapid sequence intubation, 2.23 (2.00 to 2.50), and paralytic-only intubation, 2.11 (1.38 to 3.24), and similar for sedation-only intubation, 1.04 (0.92 to 1.19). Rapid sequence intubation was also associated with higher first-pass success when compared with sedation-only intubation (2.14 [1.88 to 2.43]).

Conclusion: The use of rapid sequence intubation in patients undergoing endotracheal intubation outside of cardiac arrest was associated with higher odds of first-pass success than patients undergoing either no-medication or sedation-only approaches. Future work is needed to evaluate the association between drug-assisted airway management approach and peri-intubation adverse events and clinical outcomes.

Keywords: Airway management; EMS; First-pass success; Rapid sequence intubation.