Association of Level 3 Personal Protective Equipment With Intubation Success in the Emergency Department

Tracheal intubation is an aerosol-generating procedure that poses a high risk of infection for healthcare workers. While Level 3 personal protective equipment (PPE) is recommended, its effect on procedural performance remains uncertain. The objective of this study was to evaluate the association among Level 3 PPE use, first-pass success, and adverse events during emergency department (ED) intubation.

We analyzed data from the Japanese Emergency Airway Network-V, a multicenter prospective registry of 12 EDs in Japan. Adult patients, aged ≥ 18 years, who underwent emergency intubation between 2020 and 2022 were included. Level 3 PPE included disposable gloves, fluid-repellent gowns or coveralls, filtering face piece 3 respirators, and eye protection. The primary outcome was first-pass success, while secondary outcomes included major and minor adverse events, including hypotension, hypoxemia, cardiac arrest, and airway injury. Logistic regression with stabilized inverse probability of treatment weighting was performed to adjust for confounding variables.

Of the 2431 patients, 1159 (47.7%) were intubated with Level 3 PPE. The unadjusted first-pass success rate was higher with PPE (83.4% vs. 79.6%; p = 0.02); however, adjusted first-pass success did not differ significantly (risk difference-0.4%, 95% CI-6.3 to 5.5; p = 0.88). After adjustment, major (0.8%, 95% CI-7.1 to 8.7) and minor (0.5%, 95% CI-2.2 to 3.2) adverse events showed no significant differences.

The use of Level 3 PPE was not associated with decreased success or increased adverse events, supporting its safe use during high-risk procedures.