title: Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit.
abstract: BACKGROUND
  Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy.
  
  
  OBJECTIVE
  To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU).
  
  
  METHODS
  This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation.
  
  
  RESULTS
  There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure.
  
  
  CONCLUSIONS
  In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.|2 Department of Emergency Medicine, University of Arizona, Tucson, Arizona; and.
authors.forename: Raj
authors.initials: R
authors.lastname: Joshi
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.|2 Department of Emergency Medicine, University of Arizona, Tucson, Arizona; and.
authors.forename: Cameron D
authors.initials: CD
authors.lastname: Hypes
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.|2 Department of Emergency Medicine, University of Arizona, Tucson, Arizona; and.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Greenberg
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.
authors.forename: Linda
authors.initials: L
authors.lastname: Snyder
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.
authors.forename: Josh
authors.initials: J
authors.lastname: Malo
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.|3 University of Arizona College of Medicine, Tucson, Arizona.
authors.forename: John W
authors.initials: JW
authors.lastname: Bloom
authors.affiliation: 3 University of Arizona College of Medicine, Tucson, Arizona.
authors.forename: Harsharon
authors.initials: H
authors.lastname: Chopra
authors.affiliation: 2 Department of Emergency Medicine, University of Arizona, Tucson, Arizona; and.
authors.forename: John C
authors.initials: JC
authors.lastname: Sakles
authors.affiliation: 1 Section of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, and.|2 Department of Emergency Medicine, University of Arizona, Tucson, Arizona; and.
authors.forename: Jarrod M
authors.identifier: http://orcid.org/0000-0002-5371-0845
authors.initials: JM
authors.lastname: Mosier
mesh_terms: D000368:Aged; D001130:Arizona; D003422:Critical Care / Q000379:methods; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods*; D007828:Laryngoscopy / Q000379:methods*; D016015:Logistic Models; D055370:Lung Injury / Q000209:etiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D012137:Respiratory System / Q000503:physiopathology*; D014741:Video Recording
keywords: critical care; difficult intubation; intubation; video laryngoscopy