First-attempt success and associated factors among emergency tracheal intubations in two addis Ababa hospitals

First-pass success (FPS) in emergency tracheal intubation is a key quality metric linked to fewer intubation-related complications, but data from low-income settings are limited. This study aimed to measure FPS and identify intubation-related complications in two tertiary hospitals in Addis Ababa, Ethiopia.

We conducted a prospective, cross-sectional observational study of consecutive emergency and ICU tracheal intubations at Tikur Anbessa Specialized Hospital (TASH) and Zewditu Memorial Hospital (ZMH) from May to October 2024. Patients aged 13 years or older undergoing emergency intubations were included. Online tool was developed to collect key variables from clinicians. The primary outcome was FPS (successful endotracheal tube placement on the first laryngoscope insertion). Bivariate analyses and multivariable logistic regression were used to identify independent predictors; adjusted odds ratios (aOR) with 95% confidence intervals (CI) were reported.

A total of 112 intubations were analyzed. Median age of patients was 37.5 years (IQR 25-55); 62.5% were male. Hypoxic respiratory failure was the predominant indication (68.8%). Direct laryngoscopy was used in all cases; the most common induction strategy was ketamine (50/112 [44.6%]) with succinylcholine (67/112 [59.8%]) as the neuromuscular blocking agent. FPS was 64.3% (72/112). Additional successes occurred on the second (25.0%), third (8.0%), and ≥ 4 attempts (2.7%). One or more complications occurred in 42 out of the 112 cases (37.5%; 95% CI 28.5-46.5%), highlighting a substantial immediate adverse-event burden; cardiovascular instability occurred in 22.3%, cardiac arrest in 5.4%, and death within one hour in 2.7%. On adjusted analysis, operator training level and airway visualization were the strongest predictors: Year-II residents (aOR 46.81; 95% CI 3.03-722.72; p = 0.006) and Year-III residents (aOR 406.30; 95% CI 13.72-12,033.01; p < 0.001) had markedly higher odds of FPS compared to Year-I residents. Intubations without anticipated difficulty were more likely to succeed (aOR 10.74; 95% CI 1.01-114.45; p = 0.049). A Cormack-Lehane grade III view predicted failure (aOR 0.005; 95% CI 0.000-0.828; p = 0.042), while an abducted vocal cord favored success (aOR 23.96; 95% CI 2.93-195.76; p = 0.003).

FPS in these Addis Ababa hospitals (Tikur Anbessa Specialized Hospital and Zewditu Memorial Hospital) was 64.3%, a level we consider suboptimal compared with commonly cited benchmarks of ≥ 80%. This is lower than pooled benchmarks reported from large high-income country series (~ 79-84%) but within the range reported in some low- and middle-income settings. Operator experience and airway visualization were the dominant determinants of one-pass success. Given the high immediate complication rate (37.5%), targeted supervised training, anticipation of difficult anatomy, and prioritized expansion of airway adjuncts (e.g., bougie, phased introduction of video laryngoscopy and capnography) should be implemented to improve FPS and reduce harm in resource-limited emergency settings.