(1056) Identifying Factors Causing Prolonged Apnea During Intubation With Hyperangulated Videolaryngoscopy

Introduction: Hyperangulated video laryngoscopy (VL) has become ever more popular over the last several years for the first attempt at intubation as compared to standard geometry video laryngoscopy. This method makes obtaining an appropriate vocal cord view demonstrably easier. However, after obtaining appropriate cord view, there are several subsequent steps involved in proper and timely endotracheal intubation that may be difficult for the novice intubator and lead to unnecessarily prolonged apnea time. We sought to identify which individual steps or movements provided the most challenge in endotracheal intubation using hyperangulated VL.

Methods: We recorded and reviewed video from a consecutive sample of 55 intubations using hyperangulated video laryngoscopy performed at one mid-sized academic hospital. All intubations were performed by Emergency Medicine resident physicians. Minimally two reviewers evaluated each video and discrepancies were resolved by consensus discussion. Variables measured included grade of view, time to view of vocal cords, time to intubation, number of posterior endotracheal tube (ETT) attempts in the hypopharynx, and use of suction.

Results: Of the 55 intubations included in this study, first pass success was 85% (47/55). Mean time to successful intubation was 32 seconds. Laryngoscopic view of vocal cords was obtained in a mean of 11 seconds and 89% (49/55) were grade one or two views. By far, the largest contributors to prolonged apnea were difficulty with positioning the tube appropriately anterior and excessive suctioning. In our sample, 29% (16/55) of intubation attempts involved multiple unsuccessful posterior attempts at ETT placement that prolonged apneic time by a mean of 35 seconds.

Conclusions: Based on our study, the most challenging step of the process of intubation for residents is inability to deliver tube anterior enough, as demonstrated by a mean of 35 seconds of prolonged apneic time attributable to difficulties with tube placement. We identify this as an area for specific educational focus, particularly focusing on proper patient positioning, endotracheal tube and stylet molding, and hand positioning for delivering the ETT.