Tracheal intubation (TI) is a procedure that is frequently performed in an out-of-hospital
emergency setting. TI is associated with a risk of adverse events, including severe sequelae
such as hypoxemia, vomiting, aspiration, hypotension, and cardiac arrest. The risk of adverse
events increases dramatically with the number of intubation attempts. Thus, it is important
that the first intubation attempt succeeds. In most cases, the environment in an
out-of-hospital setting is not appropriate for intubation, and can be austere (outside,
restricted space, patient on the floor, or public place) or dangerous (mountain, sea, or
roadside). Although literature data are abundant, they are extremely heterogenous. Indeed,
the available studies differ in terms of operator profiles, TI indications, and design. Based
on studies involving management by physician-led teams in out-of-hospital settings and for
which data are available, the failure rate of the first intubation attempt ranges from 5% to
32%. Numerous variables are associated with difficult intubation (DI), such as more than two
attempts and bad glottic visualization, but few studies have analyzed risk factors for
failure of the first attempt. Identification of such factors would decrease the risk of
complications.In recent study, the prevalence of a failed first intubation attempt was 31.4%
[95% CI = 30.2-32.6] among 1546 patients managed in an out-of-hospital setting. In this
multicenter study, our center (N=462) had a rate of 36% of failure of the first attempt.
Seven variables were independently associated with a failed first intubation attempt,
operator with ≤ 50 prior intubations, small inter-incisor space, limited head extension,
macroglossia, ENT tumor, cardiac arrest, and vomiting.
Some of the associated factors can be improved (operator training and experience), but most
cannot. Moreover some of them can not be anticipated in this context. A randomized control
trial performed in an emergency department showed that systematic use of a bougie during the
first intubation attempt improved the success rate. A prospective, observational, pre-post
study design including 823 and 771 patients respectively, showed that the use of a bougie on
the first intubation attempt by paramedic in prehospital setting, improved the success rate.
So we modified our intubation modalities introducing the incitation of the use of the bougie
on the first intubation attempt in the prehospital setting.
The main objective of this study is to compare the rate of first intubation attempt in a new
observational study performed in our center with the rate of the first assessment and to
measure the impact of the introduction a systematic bougie in our intubation modalities. The
secondary objective is to measure in this new cohorte rate of first intubation attempt
between intubation with and without bougie.
The follow up will be restricted to the area of prehospital emergency setting.