title: Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data.
abstract: BACKGROUND
  Although the international guidelines emphasize early and systematic use of rescue intubation techniques, there is little evidence to support this notion. We aimed to test the hypothesis that preceding multiple failed intubation attempts are associated with a decreased success rate on the first rescue intubation in emergency departments (EDs).
  
  
  METHODS
  We analysed data from two multicentre prospective registries designed to characterize current ED airway management in Japan between April 2010 and June 2013. All patients who underwent a rescue intubation after a failed attempt or a series of failed attempts were included for the analysis. Multiple failed intubation attempts were defined as ≥2 consecutive failed intubation attempts before a rescue intubation. Primary outcome measure was success rate on the first rescue intubation attempt.
  
  
  RESULTS
  Of 6,273 consecutive patients, 1,151 underwent a rescue intubation. The success rate on the first rescue intubation attempt declined as the number of preceding failed intubation attempts increased (81% [95% CI, 79%-84%] after one failed attempt; 71% [95% CI, 66%-76%] after two failed attempts; 67% [95% CI, 55%-78%] after three or more failed attempts; P(trend) <0.001). In the multivariable analysis adjusting for age, sex, principal indication, change in methods, devices, and intubator specialty, and clustering of patients within EDs, success rate on the first rescue intubation after two failed attempts was significantly lower (OR, 0.56; 95% CI, 0.41-0.77) compared to that after one failed attempt. Similarly, success rate on the first rescue intubation attempt after three or more failed attempts was significantly lower (OR, 0.49; 95% CI, 0.25-0.94) compared to that after one failed attempt.
  
  
  CONCLUSIONS
  Preceding multiple failed intubation attempts was independently associated with a decreased success rate on the first rescue intubation in the ED.
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Goto
authors.forename: Koichiro
authors.initials: K
authors.lastname: Gibo
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Hagiwara
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Morita
authors.forename: David F M
authors.initials: DF
authors.lastname: Brown
authors.forename: Calvin A
authors.initials: CA
authors.lastname: Brown
authors.forename: Kohei
authors.initials: K
authors.lastname: Hasegawa
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D058109:Airway Management / Q000379:methods*; D004630:Emergencies; D004635:Emergency Medicine / Q000379:methods*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D007564:Japan; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome; D055815:Young Adult