Number of intubation attempts in airway management survival

Summary of the article by Casey Patrick, @cpatrick_89

Article reviewed: Murphy, DL, Bulger, NE, Harrington, BM, Skerchak, JA, Counts, CR, Latimer, AJ, … & Sayre, MR (2021). Fewer tracheal intubation attempts are associated with better neurologically intact survival after out-of-hospital cardiac arrest. Intensive care, 167289-296.

Who, what, when, where and how?

  • Who? – 1,205 non-traumatized OHCA patients with attempted endotracheal intubation, defined as “the introduction of a laryngoscope in front of the teeth and concluded when the laryngoscope was removed from the mouth, whether or not an endotracheal tube was inserted “.
  • What? – Retrospective, observational, cohort (cohort = OHCA/intubation)
  • When? – January 2015 – June 2019
  • Where? – Seattle Fire
  • How? – Primary outcome = neurointact survival (CPC1/2)
  • Excluded no attempt, BLS only, intubated after ROSC, DNR, other services

Figure/courtesy Maia Dorsett, MD, PhD, FAEMS

Figure/courtesy Maia Dorsett, MD, PhD, FAEMS


  • Age = 60, 68% male, 33% witnessed, 61% received bystander CPR, 21% shockable rhythm
  • ROSC 44%, hospital admission 38%, survival at d/c 11%
  • First successful attempt 65%, second 86%
  • Overall supraglottic utilization rate – 2.8%, 0.7% after 2 attempts, 11.2% after 3 attempts, 28.4% after 4+ attempts
  • Main result = CPC 1/2
    • There was a negative correlation between the number of ET attempts and the neurologically intact outcome: 11% CPC 1/2 with ONE intubation attempt, 4% with two, 3% with three, and 2% with four more (see picture)
    • These differences are valid for shockable and non-shockable rhythms
    • Modeling of multivariate statistics adjusted for: age/sex/control/passer/hours/initial rate

Read more:

Read more:

Training day: how paramedics should use capnography

The application of an EtCO2 sampling device and waveform monitoring, particularly during valve mask ventilation, is well within the reach of paramedics.


  • What about SGAs? This is not a rehash of PART/AIRWAYS-2. The overall SGA utilization rate was very low.
  • Average time to airway = 5 minutes in this study
  • Yes, it’s retrospective but… very granular (especially in the OHCA world)
  • Built-in monitor data PLUS audio (1,200 patients!)

What should we do now?

  • No, this does not directly translate to agencies using “Primary SGA” in OHCA
  • But, more evidence airway delays = worse patient-oriented results
    • Should there be a faster transition to the use of SGA after a failed primary intubation attempt?

The bottom line: Focus on the interventions we to know important: early recognition and proximity CPR, access to early defibrillation, minimization of pauses, appropriate rate and depth of compression.

Edited by EMS MEd Editor Maia Dorsett, MD, PhD, FAEMS (@maiadorsett)

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