Failed intubation? These are the next steps

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: 

 

• Short, thick necks
• Obesity 
• The presence of bodily fluids, such as blood or vomit
• Damage to the face or jaw 
• Dental conditions, such as overbite or the presence of dentures
• Congenital abnormalities
  
  

In addition to looking for the above factors, you should also use the LEMON technique to survey the patient and prepare them for intubation. This is one of the best techniques for determining the probability of a difficult airway. 

 

 

Take These Steps After a Failed Intubation

A study on prehospital intubations determined several common steps to take after failed intubations that increase the rate of success on the next attempt. 

 

Following a failed intubation attempt, you should:

 

1. Suction the patient’s airway after each failed attempt.
2. Reposition the patient to further open the airway.
3. Change equipment following two failed attempts.
4. Call a new operator following two failed attempts.

 

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 risks causing significant and broader complications for the patient. Thus, you should maintain 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:

 

• Progressive hypoxia, which may take three or more minutes to progress 
• Abnormal sounds in the axilla or epigastrium
• Absent or decaying capnography waveform
  
  

If esophageal intubation is suspected, the tube should be removed, and you should take the following steps: 

 

1. Use a bag mask on a patient with an oropharyngeal or nasopharyngeal airway.
2. Administer a high concentration of oxygen. 
3. Call for assistance.
4. Prepare for laryngoscopy and re-intubation when the patient is stable. 
5. Consider inserting a supraglottic airway.
   
   

 

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:

 

• Uneven chest expansion
• Unilaterally reduced breath sounds
• High airway pressure
• Oxygen saturation decreases to around 85-88%, which may take several minutes
  
  

 If bronchial intubation is suspected, immediately:

 

1. Administer high-concentration oxygen. 
2. Observe the chest and auscultate both axillae.
3. Withdraw the tracheal tube with the cuff deflated until it’s positioned in the trachea and breath sounds are heard bilaterally.
4. Ensure adequate re-expansion of the non-ventilated lung. 
5. If you believe the tube has been displaced from the trachea, pull out the tube. 

 

Having the proper equipment and knowledge can increase the chance of 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 Catheter 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 September 2022. It has been re-published with additional up-to-date content.