Description of Critical Care Transport First Pass Endotracheal Intubation Failures

Endotracheal intubation is performed by health care providers from different training backgrounds and in diverse locations. The first pass failure rate has been reported to be variable, and complications can arise from multiple intubation attempts. This is a hypothesis-generating descriptive analysis of first pass endotracheal intubation failure performed by a critical care transport team. Secondary outcomes included patient and procedural factors associated with failure.

This is a retrospective chart review of adults (≥18 years) intubated by a critical care transport service between January 2017 and June 2024. One intubation attempt was defined as the insertion of the laryngoscope past the lips. First pass failure was defined as failure to place an endotracheal tube through the vocal cords on the first intubation attempt.

There were 388 patients intubated with 54 first pass failures (13.9%). Multiple reasons for failure were cited in 20 first pass intubation failures (37.0%). The most common reasons for failure were desaturation during intubation (7; 13.0%); contamination with blood, secretions, emesis, or foreign bodies (23; 42.6%); and anatomy (33; 61.1%). There was an association between first pass failure and retrospectively documented predicted difficult airway (adjusted odds ratio, 2.96; 95% confidence interval, 1.57-5.56).

First pass failure occurred in 13.9% of intubations. This descriptive analysis serves as a starting point for further quality improvement work that includes a systematic review of intubations with objective data (ie, video-recorded laryngoscopy) and the use of an airway failure taxonomy to describe errors.