Contributor: Travis Barlock, MD

Educational Pearls:

First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma.

Complication rate for patients intubated on the first pass is 14%
Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt

How to improve likelihood of first-pass success:

Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71%
Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study cites a success rate in these patients of 96% with a bougie, compared to 82% without
Use a Checklist mnemonic (SOAPME)

Suction – On, ready, and within reach
Oxygen – Patient is preoxygenated
Adjuncts – Oral/nasal adjuncts and BVM ready
Positioning - Patient positioned properly; consider obesity, using semi-Fowler/head-up positioning
Medications – Rapid sequence intubation (RSI), sedation, vasopressor, and other medications prepared as necessary
Equipment – Laryngoscope (blade), tube, bougie/stylet, syringe, scalpel/cric kit, others ready as necessary

References

Sakles, J.C., Chiu, S., Mosier, J., Walker, C. and Stolz, U. (2013), The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med, 20: 71-78. https://doi.org/10.1111/acem.12055
Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2023;389(5). doi:https://doi.org/10.1056/nejmoa2301601
Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496
‌Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278
Turner, Joseph S et al. "Feasibility of upright patient positioning and intubation success rates At two academic EDs." The American journal of emergency medicine vol. 35,7 (2017): 986-992. doi:10.1016/j.ajem.2017.02.011

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P