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Successful endotracheal intubation following a failed first attempt during aeromedical retrieval
  1. John Glasheen1,2,
  2. Jeff Hooper1,3,
  3. Andrew Donohue1,3,
  4. Emmeline Finn4,
  5. Bronwyn Murray-Smith1,
  6. Renée Bolot1,
  7. Mark Edwards1
  1. 1 LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
  2. 2 Anaesthesia Trauma and Critical Care, Lancashire, UK
  3. 3 Gold Coast University Hospital, Southport, Queensland, Australia
  4. 4 South Australia Ambulance Service, Adelaide, South Australia, Australia
  1. Correspondence to Dr John Glasheen, LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia; john.glasheen{at}


Introduction First attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.

Methods LifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.

Results Of the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.

Conclusion Although a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

  • prehospital care, helicopter retrieval
  • airway
  • critical care transport

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  • Contributors JG and EF conceived the project. JG, RB and BM-S performed the data access. JG analysed the data and wrote the first draft. All authors edited the manuscript. ME provided overall project supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Ethical Approval was granted by the Human Research Ethics Committee, Royal Brisbane and Women’s Hospital, Brisbane, Australia. Approval reference HREC/17/QRBW/80.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. We do not have permission to share the data for this project.