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Factors associated with difficult intubation in prehospital emergency

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Article  in  European Journal of Emergency Medicine · October 2011

DOI: 10.1097/MEJ.0b013e32834d3e4f · Source: PubMed

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Factors associated with difficult intubation in prehospital
emergency medicine
Yonathan Freund, Francois-Xavier Duchateau, Marie-Laure Devaud,
Agnès Ricard-Hibon, Philippe Juvin and Jean Mantz
Objectives When managing airways in a prehospital
setting, emergency physicians have to deal with
difficult intubation (DI), which increases morbidity and
mortality. The primary goal of this study was to
determine predictors of DI in the out-of-hospital field
faced by the French physician-staffed Emergency
Medical Service.
Methods The study was a prospective, observational
study, including all consecutive patients intubated during
a 30-month period. Patients having experienced standard
c 2011 Wolters Kluwer Health | Lippincott
intubation (two attempts or less) or DI (more than two
attempts) were compared.
Results Six hundred and ninety-four patients were
included: 70 (11%) were classified as DI and 583 as
standard intubations. Logistic regression showed
that airways obstruction [odds ratio (OR), 4.1; 95%
confidence interval (CI), 1.71–14.4], intubation on
the floor (OR, 2.6; 95% CI, 1.04–6.6), and a hyoid-mental
distance less than three fingers (OR, 2.3; 95% CI,
1.2–4.7) were independent predictors of DI. Immediate
complications occurred in 89 patients (16%): 66 (11%)
Introduction
When managing airways in a prehospital setting, emer-
gency physicians have to deal with difficult intubation
(DI), which increases morbidity and mortality [1–3].
Substantial progress in research has been made over the
years in this field. A safe and effective rapid sequence
intubation (using etomidate and succinylcholine) has
been generalized, and algorithms for the management of
DI are widespread [4–6]. However, little is known about
the factors associated with prehospital DI. Most previous
studies on prehospital intubation were carried out before
the use of rapid sequence induction was generalized. In
a prehospital setting, intubation is often associated
with unexpected difficulties such as difficult environ-
ments, uncomfortable positions, or lack of experience of
emergency physicians in charge of the patients. For these
reasons, early identification of patients at risk of DI is
of major interest because alternative techniques and/or
airway rescue tools can be anticipated [7]. Therefore, the
primary goal of the present study was to determine
predictors of DI in the out-of-hospital field by French
Emergency Medical Services (EMS).
0969-9546
c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Original article 1
in the standard intubation group and 23 (31%) in the
DI group (P < 0.01).
Conclusion For prehospital orotracheal intubation,
independent risk factors of DI are a mental-thyroid
distance less than three fingers, a patient on the floor, and
a superior airways obstruction. Anticipation of DI could
result in fewer attempts, and fewer complications, as the
rate of complication increases with the difficulty of
intubation. European Journal of Emergency Medicine
00:000–000
Williams & Wilkins.
European Journal of Emergency Medicine 2011, 00:000–000
Keywords: airways, difficult intubation, emergency, prehospital
Department of Anaesthetics and Intensive Care, Beaujon University Hospital,
Clichy, France
Correspondence to Yonathan Freund, MD, Emergency Department,
Pitié-Salpêtrière Hospital, 47-83 Boulevard de l’hôpital, 75013 Paris, France
Tel: + 33 1 42177912; fax: + 33 1 42177242;
e-mail: yonathanfreund@gmail.com
Received 22 July 2011 Accepted 16 September 2011
Methods
Study design
The study was a prospective observational study, which
was conducted in the EMS unit of a teaching hospital,
covering an area of 290 172 inhabitants during a 30-month
period. The study has been approved by the Institutional
Review Board of Paris – North Hospitals, Paris 7
University, Assistance-Publique – Hôpitaux de Paris.
As a part of the French EMS system, physician-staffed
ambulances are deployed if a particularly severe or life-
threatening condition is suspected. The teams include a
physician, a nurse, and a paramedic. When intubation is
indicated, patients are intubated by an emergency
physician, or by an anesthestic nurse with substantial
experience in both the EMS and operating theaters.
Physicians are specialized in emergency medicine or
anesthetics and have at least 2 years experience in
prehospital EMS care. From April 2008 to October 2010,
10 225 such ambulances were deployed, and 694 patients
were intubated. Metal, single-use or reusable, laryngo-
scope blades with similar first-pass success were used [8].
DOI: 10.1097/MEJ.0b013e32834d3e4f
 2 European Journal of Emergency Medicine 2011, Vol 00 No 00

All consecutive intubated patients were included, and the Results

data were collected under the supervision of a senior
attending. All forms were completed by the physician
who performed intubation.
Definition of difficult intubation
According to the French Society of Anaesthetics and
Intensive Care (Société Française d’Anesthésie Réanima-
tion), a DI is considered present after two failed
laryngoscopic attempts for tube placement, or when
alternative measures are needed to ensure successful
intubation. On the basis of this definition, patients were
recorded as follows:
(1) If more than two attempts were needed to obtain a
proper endotracheal tube placement, the intubation
was recorded as difficult.
(2) If an alternative technique was preventively and
successfully used (such as a gum elastic bougie)
before the third attempt, then the patient was
excluded, for we could not assess the difficulty of
the process.
(3) In other cases, when the procedure was successful in
less than three attempts without using alternative
techniques, the intubation was recorded as a standard
intubation (StI).
Six hundred and ninety-four patients were intubated
during the study period. Of these patients, 41 were
excluded because an alternative technique was preven-
tively used at the physician’s discretion during the first or
the second attempt and the patients were successfully
intubated before the third attempt (Fig. 1).
Demographic data
The mean age was 60.5 years, and the sex ratio was 1.6
(62% men). Three hundred and sixty-four (56%) patients
presented with cardiac arrest at the time of the
intubation, and were intubated without sedation. Among
the remaining 330 patients, 289 patients underwent rapid
sequence intubation. Seventy patients (11%) were
classified as DI and 583 as StI. Median number of
attempts was one (Fig. 2). In the DI group, median
number of laryngoscopic attempts was three (3–3.75).
Fig. 1
694 Patients
consecutively
intubated

Patients were divided into two groups: StI (two attempts

41 Excluded
or less) or DI. Variables recorded included age, sex, (alternative technique
estimated weight and height, Cormack classification, before the third attempt)
position of the patient during the procedure (on a bed,
on a stretcher, on the floor), medical condition of the
patient (cardiac arrest or other cause), drugs used for
induction, hyoid-mental distance, the presence of an
583 Standard
airways obstruction [or ear–nose–throat (ENT) pathol- 70 Difficult
intubations
ogy], number of attempts at intubation, possible alter- intubations (DI)
(Sti)
native techniques, and immediate complications. These
were compared between the two groups. Flow chart.

Statistical analysis
Expecting a DI rate of about 10%, and requiring a
minimum of 50 patients for the multivariate analysis, we Fig. 2
estimated that the sample size should exceed 500
Attempts
patients. All collected data were included in univariate 500
analysis, and factors statistically associated with a DI were 450
then pooled in the multivariate analysis. Results are 400
reported as mean values ± SD for continuous variables 350
300
and medians with interquartile ranges for discontinuous
250
data. Qualitative data are expressed as the percentage of 200
patients. Statistical analysis was performed using a 150
one-way ANOVA for quantitative data and a w2 test for 100
qualitative data. A multivariate analysis was also per- 50
0
formed, with all variables significantly associated with DI. 1 2 3 4 5 6 7
Statistical significance was defined as P < 0.05. Stat-View
5 (Abacus Concept, Berkeley, California, USA) was used Number of attempts.
for analysis.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Factors associated with difficult intubation Freund et al. 3

Cormack classification Table 3 Logistic regression

One hundred and eighty-six (28%) of the intubated Variable OR 95% Confidence interval P
patients were classified as Cormack 1, 389 (60%) as
Patient on the floor 2.60 1.04–6.6 0.04
Cormack 2, 55 (8%) as Cormack 3, and 22 (3%) as Cardiac arrest 1.60 0.796–3.195 0.19
Cormack 4. The Cormack classifications were signifi- Hyoid-mental < 3 fingers 2.34 1.157–4.745 0.02
cantly different depending on whether the intubation was Airways obstruction 4.09 1.171–14.278 0.03

considered to be difficult or not as shown in Table 1. OR, odds ratio.

The Cormack score was not analyzed as a predictive

factor of DI, because this criteria was unknown before
the patient is intubated. airways lesions (three in the DI and three in the StI
groups, respectively), oxygen desaturation (six in the DI
Factors associated with DI and 19 in the StI groups, respectively), and cardiac arrest
It was found that a mental-hyoid distance of less than (six in the DI and thee in the StI groups, respectively).
three fingers was more likely to be present in patients
undergoing a DI (16 vs. 9%, P = 0.03). Furthermore, Discussion
patients handled on the floor (89 vs. 68%, P < 0.001), The definition of DI used in this study is a pragmatic
patients with cardiac arrest (74 vs. 54%, P = 0.001), and comment on the difficulty of the procedure, rather than a
patients with obstructive airways conditions (6 vs. 1%, characteristic of the patient being intubated. In the field
P = 0.02) were more often present in the DI group. of prehospital medicine, this ‘real-life’ evaluation of the
Obese patients (defined as those with a BMI > 30) were difficulty is of much more interest than what difficulty
not found significantly more likely to present a DI. the intubation could pose under optimal conditions.
Univariate comparison is shown in Table 2.
The findings of this study can be summarized as follows:
Logistic regression showed that an airways obstruction airway obstruction, a hyoid-mental distance of less
[odds ratio (OR), 4.1; 95% confidence interval (CI), than three fingers, and a patient intubated on the
1.71–14.4], a patient intubated on the floor (OR, 2.6; 95% floor, were all independent predictors of DI in the
CI, 1.04–6.6), and a hyoid-mental distance less than three prehospital setting.
fingers (OR, 2.3; 95% CI, 1.2–4.7) were independent
The rate of DI observed (11%) is consistent with pre-
predictors of DI, as shown in Table 3.
existing literature [9–11] in which the same EMS system
Immediate complications occurred in 89 patients (16%): experiences rates of 2 [10] to 20% [12]. In a recent large
66 (11%) in the StI group and 23 (31%) in the DI group monocenter study, including 1442 consecutive out-
(P < 0.01). In the two groups, complications were: of-hospital intubations, the rate of DI was of 7.4% [9].
esophageal intubation (12 in the DI group and 21 in For paramedic-staffed EMS systems, the incidence has
the StI group), aspiration of gastric content (five in the been reported as up to 36% [13–15]. These variations
DI and six in the StI groups, respectively), dental or may result from the absence of a strict definition of DI,
and from major differences in staff.
Table 1 Cormack classification in the two groups Many factors have been associated with a DI based on
Difficult intubation Standard intubation the anaethetics and emergency medicine literature, for
Cormack classification N = 70 (%) N = 583 (%) P example, hyoid-mental distance of less than three fingers,
1 16 (23) 170 (29) < 0.001 thyroid-hyoid distance of less than two fingers, obesity,
2 22 (31) 367 (63) — poor neck mobility, obstructed airways, large tongue, and
3 18 (25) 37 (6) —
4 14 (20) 8 (1) —
large incisors. Most of these factors remain controversial,
especially obesity [11,16–18]. A recent study conducted
in an emergency department [19], showed that thyroid-
hyoid distance of less than two fingers was the sole
Table 2 Univariate analysis for determining difficult intubation
independent variable predictive of DI. The presence of a
StI DI P short neck (mental-hyoid distance less than three fingers,
N (%) 553 (89%) 70 (11%) or hyoid-thyroid distance less than two fingers), has been
Age 60.2 ± 19.3 63.2 ± 16.3 0.16 repeatedly proven to be an independent predictor of
Sex (Male) 224 (62%) 45 (64%) 0.7
BMI > 30 69 (12%) 13 (19%) 0.11 DI [11,19,20], as has the presence of an airways
Patient on the floor 397 (68%) 62 (89%) < 0.01 obstruction (for example facial trauma, or ENT neopla-
Cardiac arrest 312 (54%) 52 (74%) 0.001
Hyoid-mental < 3 fingers 52 (9%) 11 (16%) 0.03
sia). The impossibility for the operator to stand up has
Airways obstruction 9 (1%) 4 (6%) 0.02 also been described as an independent predictor of
Cervical immobilization 47 (8%) 5 (7%) 0.79 DI [9]. We found a strong association between intubation
Mean age ± standard deviation. on the floor and DI. This new finding is of importance,
DI, difficult intubation; StI, standard intubation. because of its uniquness to the prehospital setting.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 4 European Journal of Emergency Medicine 2011, Vol 00 No 00
Indeed, it could not have been observed in the operating
room or the emergency department for obvious reasons,
so pre-existing literature is not available for comparison.
Orliaguet et al. [10] performed a prospective study in the
field of the French physician-staffed EMS system, which
exhibits some similarities with the present one, although
DI was defined differently. Similarly to our study, a
history of ENT and maxillofacial trauma were factors
independently associated with prehospital DI, whereas
patients in cardiac arrest were no more likely to present a
DI. Operator’s position during intubation (standing,
kneeling, decubitus) was also identified as an indepen-
dent factor, which could be correlated with the position of
the patient (on the floor, on a stretcher, on a bed) in this
study. However, Combes et al. [9] also found that operator
status (resident) was associated with a higher DI rate.
Status of the operator was recorded but not analyzed in
the present study because governing policy recommends
switching the operator to a senior physician or a
anesthetics nurse in case of failure at the first attempt.
Finally, although higher BMI was identified as a risk factor
for DI in the Combes study (OR, 1.0; 95% CI, 1.0–1.1),
and elsewhere in the literature [17,21], we could not find
any significant association between a BMI greater than 30
and DI. As emphasized by Brodsky et al. [17], there are
many reasons for this discrepancy. First, the standard
sniffing position for tracheal intubation differs between
obese and nonobese patients. Second, the different
studies do not endorse the same definition of DI; as
difficult laryngoscopy is not synonymous with DI, using
the Cormack grade for the definition of DI could lead to
judgement bias. Again, obesity remains a controversial
predictor of DI.
Another original finding was the association between DI
and immediate complications, suggesting that DI con-
tributes to significantly higher morbidity and mortality.
This result strengthens the view that DI is a major
concern in the practice of the EMS, and that identifying
risk factors for DI could contribute appreciably to
ameliorating morbidity and mortality in this setting. An
early identification of predictors of DI could lead to
preventive use of alternative techniques to avoid
complications. The operator should expect a higher risk
of complications when facing a patient with airway
obstruction (such as ENT neoplasia for example), a
hyoid-mental distance of less than 3 cm, or a patient on
the floor, which are the predictors of DI identified here.
Rapid and reliable identification of these factors is
essential in the EMS field, where the rate of DI is much
higher than in the operating room.
There are some limitations in this study. A strict
definition of DI was used, that is, the absence of a
successful intubation after two attempts. The French
Society of Anesthesia and Intensive Care suggests that
instances requiring the use of an alternative technique
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
should be added to the ‘DI’ situations [20]. We chose to
exclude patients who underwent a successful intubation
with the use of an alternative (such as gum elastic
bougie) before the third attempt, for we could not state
whether the intubation would have been difficult or not.
The greater specificity gained from this decision could
have been at the expense of the exclusion of some DI
patients from the analysis. Also, although data were
collected from a standardized form, the process was not
blinded, creating a possible selection bias for the two
groups. Finally, as a monocentric study, our results may
not apply to all prehospital units, nor even other EMS
systems, but independent risk factors of DI may apply
regardless of the grade or specialty of the operator.
Conclusion
The identification of risk factors for DI in the prehospital
emergency context is of major concern, as DI is associated
with significant morbidity. Anticipation of DI could result
in fewer attempts to succeed, and fewer complications, as
the rate of complications increases with the difficulty of
intubation. The presence of one or more of the predictors
of DI (mental-thyroid distance less than three fingers, a
patient on the floor, and a superior airways obstruction)
should lead to the anticipation of the need to use
alternative techniques for out-of-hospital airway control.
Acknowledgements
The authors would like to thank Dr E.C. Baker (King’s
college hospital, London, UK) for having reviewed and
improved our work.
Conflicts of interest
There are no conflicts of interest.
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