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GENERAL ARTICLES

Validation of a Simple Algorithm for Tracheal Intubation: Daily Practice Is the Key to Success in Emergencies— An Analysis of 13,248 Intubations

Department of Anesthesiology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland.

Address correspondence and reprint requests to Thomas Heidegger, Department of Anesthesiology, St. Gallen Cantonal Hospital, 9007 St. Gallen, Switzerland. Address e-mail to thomas.heidegger{at}kssg.ch

A fundamental skill of the anesthesiologist is airway management. We validated a simple endotracheal intubation algorithm with a large proportion of fiberoptic tracheal intubations used for years in daily practice. Over 2 yr, 13,248 intubations (>90% of all intubations, including obstetrics and ear, nose, and throat patients) in a heterogeneous patient population at our acute care hospital were evaluated prospectively. About 80 physician and nurse anesthetists were involved. Once the indication for intubation (oral or nasal) was established, the first step was to choose between the primary conventional technique (laryngoscope with Macintosh blades) and the primary fiberoptic technique. For the conventional technique, a well defined procedure had to be followed (maximum of two attempts at intubation; if unsuccessful, switch to secondary oral fiberoptic intubation). For the primary fiberoptic technique, the anesthesiologist had to decide between nasotracheal intubation in awake patients and oral intubation in anesthetized patients. Fiberoptics were used for 13.5% of the intubations. By following our algorithm, intubation failed in 6 out of 13,248 cases (0.045%; 95% confidence interval 0.02%–0.11%). We demonstrate that a simple algorithm for endotracheal intubation, basically limited to fiberoptics as the only aid, is successful in daily practice. Only methods that are practiced daily can be used successfully in emergencies.

Implications: The aim of this investigation was to validate a simple tracheal intubation algorithm used in daily practice for years as a quality control exercise. With the exception of the guidewire, the only airway management instrument used was the fiberoptic bronchoscope. Of 13,248 intubations evaluated (90.6% of all intubations), only six patients (0.045%) could not be intubated by following our algorithm. The high proportion of primary fiberoptic intubations (12.1% of all intubations) has resulted in a corresponding degree of practice and experience with this method, with the consequence that the number of unanticipated failed intubations is very small. Daily practice is the key to success in the emergency situation.

This article has been cited by other articles:

				T. Heidegger, H. Gerig, V. K. Arya, and A. Dutta Anticipated Difficult Airway: The Role of Fiberoptics * Response Anesth. Analg., October 1, 2002; 95(4): 1124 - 1125. [Full Text] [PDF]

				H. J. Gerig, T. Heidegger, B. Ulrich, R. Grossenbacher, and G. Kreienbuehl Fiberoptically-Guided Insertion of Transtracheal Catheters Anesth. Analg., September 1, 2001; 93(3): 663 - 666. [Abstract] [Full Text] [PDF]

				J. J. Henderson The Implications of Different Failed Endotracheal Intubation Rates Anesth. Analg., July 1, 2001; 93(1): 241 - 241. [Full Text] [PDF]