You’re responding to the scene of a snowboarding accident, where a young woman in her mid-20s sustained a head injury following an attempted jump. While surveying her, you discover she is suffering aspiration due to vomitus, and you know that you must clear her airway and intubate immediately. However, you also know that the presence of potential obstructions in the airway may make intubation more difficult.
Failed intubations are an unfortunate reality in the field and can lead to severe, even fatal, consequences for the patient. This means that understanding how to properly respond to a failure is as important as trying to avoid the situation entirely.
Factors Contributing to Failed Intubation
Many factors may lead to a difficult airway and make intubation more challenging. Some of the more common factors are:
In addition to looking for the above factors, you should also use the LEMON technique as you survey the patient and prep them for intubation, as this is one of the best techniques for determining the probability of a difficult airway.
Steps to Take After Failing to Achieve Intubation
A study on prehospital intubations determined there are several steps commonly taken after failed intubations that increase the rate of success on the next attempt.
Following a failed intubation attempt, you should:
If the third attempted intubation fails, do not try again. Multiple repetitions of the same failing technique can lead to a “can’t intubate, can’t ventilate” scenario. Instead, other methods should be used, such as a supraglottic airway.
Injury Caused by a Failed Intubation
Failed intubation is commonly caused by an incorrectly placed tube, which poses the risk of causing significant and broader complications for the patient. Thus, you should keep a high index of suspicion regarding tube placement — particularly in patients with difficult airways.
Esophageal Placement
During intubation, it’s not uncommon for the tube to be accidentally placed in the esophagus rather than the trachea. If not recognized early, esophageal intubation may later present itself as a cardiovascular abnormality or collapse, making correct diagnosis much more difficult.
Reliable signs of esophageal intubation are:
If esophageal intubation is suspected, the tube should be removed, and you should take the following steps:
Bronchial Placement
Bronchial intubation occurs when the tube is advanced too far during intubation and a bronchus is isolated, potentially leading to an overinflated lung. This can cause serious medical issues, such as the collapse of the unventilated lung or scarring of the bronchial mucosa.
Signs of bronchial intubation include:
If bronchial intubation is suspected, immediately:
Having the proper equipment and knowledge can increase the chance of a successful first-attempt intubation in a difficult airway. However, when an intubation attempt fails, suctioning after each attempt is one of the critical steps to achieve success on the next try. The SSCOR DuCanto Cather can help you achieve successful intubation, as it’s designed for use during emergency airway management and is an effective suction tool when intubating.
Unfortunately, patients can and do sustain injuries due to failed and inadequate intubation. If this is the case, you must be able to recognize the issue and respond quickly to prevent any further damage.
Regardless of the situation at hand, being vigilant and knowledgeable increases the likelihood of a successful outcome.
Editor's Note: This blog was originally published in February 2022. It has been re-published with additional up-to-date content.