Take

a
Deep
Breath
Rethinking Endotracheal Intubation

Patrick Reed, BSN, RN, EMT-P

Crystal Molina, BSN, RN
Emergency Department

Background

Placement of an endotracheal tube (ETT) is an

invasive procedure that is done to help patients
have a patent airway when theirs is compromised.

Adverse events (AE) are serious complications of

ETT placement.
Sakles et al. (2013) 72.9% first attempt intubation
Over 1/3 of intubations require more than one attempt
AE occurred in 53% of patients with multiple attempts
AE can cause severe complications to the patient

Purpose

The purpose of this project is multifocal:

Nursing education;
Performance Improvement/Clinical practice guidelines;
Patient safety;
Recognition of ETT placement complications; and
Prevention of ETT placement complications.

The purpose of this project is not:

To presently expand the scope of practice of all RNs to include
placement of ETT; and
To teach the procedure for endotracheal intubation.

Desired Outcomes:
Recognition and application of safe and competent clinical practice
with ETT placement;
Reduction of ventilator associated pneumonia (VAP) and secondary
airway trauma due to AEs; and
Structured, timely ETT placement under medical supervision.

Review of the Literature

We reviewed ___ articles regarding pre-hospital and inhospital placement of an advanced airway, specifically
endotracheal tube.

UMC In-hospital data

CERNER

retrospective analysis

Data collected on ETT adverse events

(AE)
Esophageal intubation
Mainstem intubation

NEAR Database
Coordination

with Robert Kilgo, MD

on the National Emergency Airway
Registry (NEAR) is a multicenter,
prospective emergency medicine led
registry.

Step 2: Course Intubation-Include for each course

A Course includes one method, one or more attempts by one or multiple intubators, and one set of medications.
A. Method (Check only one. Begin another course if a second method was
used.)

j Nasal
lk
m
n
j
lk
m
n

- no meds

Nasal - topical or sedation

B. Device (Check only one. Begin another course if a second

device was used.)

j Surgical
lk
m
n

- Cricothyrotomy

j Fiberoptic -flex
lk
m
n

j I-LMA only
lk
m
n

j Surgical
lk
m
n

- needle

j Fiberoptic -rigid
lk
m
n

j Percutaneous needle
lk
m
n

- Tracheostomy

j Percutaneous cric set

lk
m
n

j Oral
lk
m
n

- RSI (must specify paralytic below)

j Surgical
lk
m
n

j Oral
lk
m
n

- sedation without paralysis

j Digital Intubation
lk
m
n

j LMA
lk
m
n

j Surgical cric set

lk
m
n

j Other
lk
m
n

j I-LMA with intubation

lk
m
n

j Other
lk
m
n

j Special device (specify in Part B)

lk
m
n
j Oral
lk
m
n

- awake, topical or sedation

j Laryngoscope
lk
m
n

j Oral
lk
m
n

- no meds

j Laryngoscope with Bougie

lk
m
n
j Lighted stylet
lk
m
n

C. Difficulty airway indicators (Click each for a description.)

D. Attempts at intubation. Choose at least one.

(For EACH attempt at intubation, fill out one line, including all
requested information)
# Attempted By
Discipline
Supervised by EM?

1. Neck Extension
2. Mallampati

3. Mouth Opening

Y/N

Other:

Y/N

Other:

Y/N

Other:

Y/N

Other:

Y/N

Other:

4. Thyromental Distance
5. Obstruction Present?

Y/N

6. Facial Trauma/Anatomical Barrier

Y/N

c
d
fe
g

Unable to assess (enter reason below):

5
E. Medications used for intubation (Enter dose for applicable medications.)
Pretreatment Dosage
Paralysis Dosage
Induction Dosage
mg Atropine

mg Pancuronium

mg Droperidol
mg Rocuronium

mcg Fentanyl
mg Haloperidol

mg
Succinylcholine

mg Lidocaine

F. Course Success

mg Diazepam

Successful Intubation:
Y/N

mg Etomidate

If failed and no further course attempted, please explain:

mg Ketamine
mg
Methohexital

mg Vecuronium

mg Midazolam

mg
Pancuronium

mg Pentothal

mg Topical
Anesthesia

mg Propofol

mg Vecuronium

OR
c No drugs used
d
fe
g
G. Intubation events (Check all that apply.)

H. Intubation difficulty (Check all that apply.)

c
d
fe
g

NONE

Was increased lifting force necessary?

Y/N

Cardiac arrest

g
c
d
fe
c
d
fe
g

Laryngospasm

g
c
d
fe
c
d
fe
g
c
d
fe
g
c
d
fe
g
c
d
fe
g
c
d
fe
g
c
d
fe
g
c
d
fe
g

Main stem intubation

Was external laryngeal manipulation (BURP) used?

Y/N

Dental trauma

c
d
fe
g

Malignant hyperthermia

Vocal cords were adducted (closed)

Direct airway injury

c
d
fe
g

Medication error

Y/N

Dysrhythmia

c
d
fe
g

Pneumothorax

Epistaxis

c
d
fe
g

Vomit- no aspiration

Esophageal intubation, delayed recognition

c
d
fe
g

Vomit- aspiration

Esophageal intubation,immediate recognition

c
d
fe
g

Other

Hypotension-required IV fluid

I. Glottic exposure (Check only one.)

J. Disposition (Check only one.)

j I = Visualized entire vocal cords

lk
m
n

j
lk
m
n

j II = Visualized part of cords

lk
m
n

j
lk
m
n

Died in ED - failed airway

j III = Visualized epiglottis only

lk
m
n

j
lk
m
n

Died in ED - other cause

j IV = Nonvisualized epiglottis
lk
m
n

j
lk
m
n

OR

j
lk
m
n

Extubated in ED

j
lk
m
n

Transferred

j
lk
m
n

Other

Copyright 2002 NEAR. All Rights Reserved.

ICU

Methods

We performed a retrospective CERNER chart review of

patients with an in-house ETT placement.
We reviewed data from UMC of El Paso across all
departments including the Emergency Department, Intensive
Care Units, and throughout the facility including secondary
responses from the Rapid Response Team (RRT) and Difficult
Airway Response Team (DART).
We recorded the following data:

Patient demographics;
Emergency department/medical admission diagnoses;
Clinical indications for endotracheal intubation;
Personnel present;
Number of attempts;
Success or failure in ETT placement: and
Medications used as part of Rapid Sequence Intubation (RSI).

We compared UMC data with national standards.

Data
6
5
4
Series 1
Series 2
Series 3

3
2
1
0

Category 1

Category 2

Category 3

Category 4

Data
Pending

Principle Findings

We found that ___% of patients admitted required ETT

placement.

Of this population, ____% required emergent intubation.

Average intubation times are ___.

Average amounts of AEs are ____.

Results
Pending

Recommendations
The traditional approach to advanced airway placement should be
examined.
The RN should have a defined, active role in the placement of ETT in
patient advocacy and overall patient safety.
The interdisciplinary team should be coordinated with a focus not on
the procedure of ETT placement but safe, competent airway
management:

ETT placement should require a time-out pre-procedure checklist.

ETT placement should be timed and structured and all data recorded.
ETT placement should consider activation of the newly-formed DART.

UMC Policy P-53 should be reviewed.

Amendments may include results of this study

A unit-specific RN competency for ETT placement should be created;

Use of the Difficult Airway blue band should be a facility-wide
compliance.

Team hierarchy should be as follows:

Recommendations

DART Record sheet

Date: __________ Room # / Location: __________ Time Called: _________ Arrival Time: _________ Event Ended: __________

Primary Reason for Call:

as

Known Difficult Airway Patient

Respiratory Distress

Recommendations / Interventions:
Airway/Breathing
Oral Airway

Nebulizer

Bi PAP

Intubated Endotracheal

ABG

No Intervention

Surgical Cricothyrotomy Supraglottic Airway

Medication (s):
________________________________________________________
________________________________________________________
________________________________________________________
Other Interventions
Specify:
________________________________________________________
________________________________________________________
________________________________________________________
Notified Primary Physician:
Name: ____________________________________ Time: _______

Situation:
______________________________________________
______________________________________ ________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
____________________________________________ __
AdmittingDx:
______________________________________________
______________________________________________
______________________________________________
______________________________________________

Surgeon Attending Signature: (if applicable)

_______________________________________________________
Physician Printed Name ______________________ Time: _______
Surgery Chief Resident Signature: (if applicable)
_______________________________________________________
Physician Printed Name ______________________ Time: ________
Anesthesia Physician Signature:
_______________________________________________________
Physician Printed Name ____________________ Time: __________

Assessment:
Temp _____ BP _____ HR ____ RR ______ SpO2 _____ GCS_______
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Outcome: Stayed in room Transferred to ICU Transferred to IMC
Transferred to Telemetry

Code Team Activated

Other: __________________________________________
CRNA Signature: (if applicable)
_______________________________________________________
CRNA Printed Name ______________________ Time: ________

Scribe
Signature: ____________________________ Date/Time: _____________

RN Signature ___________________________________________

Scribe Printed Name and Title

_____________________________________________________________

RN Printed Name ________________________

Time: ________

Patient Identification Label

DIFFICULT AIRWAY
RESPONSE TEAM RECORD
640-058-15

White - Medical Record

Yellow: Attach to Evaluation

Education
Defining

clear roles for the team

placing a definitive airway
Determining nursing knowledge and
providing ongoing nursing education
Verifying nursing competencies
Simulation practice
Knowledge of unit
Knowledge of critical supplies
Knowledge of DART

Roles of the Team

Physicians evaluate airway per LEMON

acronym
Look
Evaluate 3-2-2 Rule
Mallampati Score
Obstruction
Neck Mobility

Registered
Nurses
ensures
all
equipment
bedside,
continuing
evaluation pre/intra/post procedure.

Mallampati Score

Roles of the Team

Physicians

generally do not conduct

ongoing
assessment
of
ETT
placement past CXR
Tulane University Health Sciences Center
Simulation Center Checklist
Is this list look anywhere near complete?

Roles of the Team

Registered Nurses conduct ongoing assessments

of the airway
Pt position
Tube placement
Equal breath sounds
End Tidal carbon dioxide concentration
Waveform capnography
Oro/nasogastric suctioning

Respiratory Therapy conducts management of

ventilator, oxygenation, and suctioning
ETT suctioning RN competency
Equipment failure management

Discussion, Implications, and

Importance

How do we implement findings of this study?

Improved nursing education

Repeated airway assessment post intubation
UMC Nursing Competency for ETT placement
UMC Policy updates on airway management to coincide with DART
Time-out on elective/non-emergent intubation
Use of standardized hospital-wide ETT placement checklist

Reduce occurrence of AEs

Reduce hospital acquired conditions/nosocomial infections
from ETT

Enhanced Checklist

Conclusions

The traditional approach to advanced airway placement

should be examined.
An interdisciplinary team of MD, RT, and RN
The RN should have a defined, active role in the
placement of ETT.

Acknowledgments
Alan H. Tyroch, M.D.
Professor and Chief of Surgery/Trauma Medical Director

Robert W. Kilgo, M.D.

Clinical Assistant Professor, Department of Emergency Medicine

Julie Gest, MS, EdS, RN

Nurse Residency Program Coordinator

Sandra Gonzalez, MSN, RN

Director of Trauma, Neurosurgery, and Adult Med/Surg Critical Care Services

Blas Meza, RN
Director of Emergency Department

Eric Johansen, MSN, MBA, RN

Nurse Manager of Emergency Department

References
Sakles, J.C., Chiu, S., Mosier, J., Walker, C., and Stolz, U.
(2013). The Importance of First Pass Success When
Performing Orotracheal Intubation in the Emergency
Department. Academic Emergency Medicine; 20, 7178. http://dx.doi.org/10.1111/acem.12055