Structured correction after difficult direct laryngoscopy during prehospital rapid sequence intubation: an...

Difficult laryngoscopy during prehospital rapid sequence intubation may lead to procedural failure and serious adverse outcomes. Evidence is limited regarding whether a structured correction bundle can convert an initial poor view into successful intubation before declaring failure. We evaluated the outcomes of a structured correction protocol used after a poor initial laryngoscopy view during physician-staffed helicopter emergency medical service rapid sequence intubation.

We conducted a retrospective observational study using prospectively collected data from the Hungarian Air Ambulance airway registry. Patients older than 14 years with maintained circulation who underwent a tracheal intubation attempt between 2012 and 2022 were included. The primary endpoint was the proportion of successful tracheal intubations after at least one corrective maneuver among cases requiring corrective maneuvers. Secondary endpoints included the success rates of individual maneuvers and associations between corrective maneuvers and prespecified covariates.

Among 2,431 included patients, 1,827 (75.2%) intubations were successfully performed without the need for any corrective maneuvers. The primary endpoint, frequency of successful intubations after at least one corrective maneuver, was achieved in 578 out of 604 cases (95.7%; 95% CI 98.4-99.3). First-pass success in the full cohort was 92.8% (2,255/2,431; 95% CI 91.7-93.8), and overall intubation success was 98.9% (2,405/2,431; 95% CI 98.4-99.3). In 63.7% (385 of 604) of the correction cases, only one maneuver was required. The most common single maneuvers were suction and backward-upward-rightward pressure, each associated with 100% success. The combination of multiple correction elements was also associated with a high success rate. Male sex, cricoid pressure, head-elevated laryngoscopy position, and non-anesthesiology operator specialty were all associated with a higher risk of requiring corrective maneuvers.

In this standardized prehospital rapid sequence intubation system, a structured correction protocol after an initially poor direct laryngoscopy view was associated with high rates of subsequent intubation success.