Intubation is indicated for patients who are struggling to breath unassisted, or who have obstructed breathing. Because respiratory function can become compromised for a wide range of reasons, intubation is a highly common procedure, though not without its risks. In fact, several preliminary studies have indicated that tracheal intubations performed by residents may increase risk of complications or other adverse outcomes, particularly in cases of multiple intubation attempts.1,2 These findings present a difficult conundrum: on the one hand, the complications of failed intubation can be severe and long-lasting, increasing the risk of respiratory and cardiovascular damage as well brain death.3 On the other hand, residents require hands-on training to learn this valuable procedure, and it is not always possible for a more experienced doctor to be on-hand when an intubation is required. Finally, given the overall low rate of complications related to intubation, gathering sufficient evidence to show a correlation between training years and outcome to measure intubation success has remained a challenge.
To this end, authors Goto et al. sought to characterize the correlation between intubation success rates and number of years of postgraduate training, so that the relative risk of a resident-performed intubation might be better understood and evaluated.4 In order to obtain a large enough sample population, data was accumulated from fifteen institutions between the years 2012 and 2019 as part of the second Japanese Emergency Airway Network prospective cohort study. Ultimately, over 8,000 patients requiring intubation were included in the study, with a median age of 71 years. Residents were considered physicians having completed less than five postgraduate years. The authors used multivariable linear and logistic regression models to define the relationship between years of postgraduate training and intubation success.
The authors reported that years of experience were significantly positively correlated with intubation success: for example, the risk of failed intubation was 23 percent higher for first-year residents as opposed to physicians with six years of experience. Given that the overall complication rate for intubation was 16 percent for all intubated patients, this difference was unexpectedly substantial. As maintained by Goto et al.,
“Although there is currently no consensus on the degree of the differences in success rate by PGYs that can be allowed for patient safety, the approximately 20% lower success rate by PGY1 physicians observed here is not acceptable for ED patients.”
The authors stipulate that a number of factors related to inexperience – for example, excessive applied force on oral structures or delaying/prolonging the insertion procedure – may have contributed to the disparities noted in their findings.
In order to improve patient safety as well as resident learning, Goto et al. note that several educational measures have already been proposed: for example, practicing intubations in the operating room, performing simulations, and conducting the procedure under the watchful eye of an experienced supervisor. However, more research will be necessary to evaluate the efficacy of these interventions before they are implemented within institutional curriculums for the training of resident physicians.
References
1 Hasegawa, K., Shigemitsu, K., Hagiwara, Y., Chiba, T., Watase, H., Brown, C. A., 3rd, Brown, D. F., & Japanese Emergency Medicine Research Alliance Investigators (2012). Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Annals of emergency medicine, 60(6), 749–754.e2. https://doi.org/10.1016/j.annemergmed.2012.04.005
2 Monette, D. L., Brown, C. A., 3rd, Benoit, J. L., McMullan, J. T., Carleton, S. C., Steuerwald, M. T., Eyre, A., Pallin, D. J., & NEAR III Investigators (2019). The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations. AEM education and training, 3(2), 156–162. https://doi.org/10.1002/aet2.10316
3 Adriani, J., Naraghi, M., & Ward, M. (1988). Complications of endotracheal intubation. Southern medical journal, 81(6), 739–744. https://doi.org/10.1097/00007611-198806000-00014
4 Goto, T., Oka, S., Okamoto, H., Hagiwara, Y., Watase, H., & Hasegawa, K. (2022). Association of Number of Physician Postgraduate Years With Patient Intubation Outcomes in the Emergency Department. JAMA network open, 5(4), e226622. https://doi.org/10.1001/jamanetworkopen.2022.6622