Respiratory Therapist Endotracheal Intubation Practices

Discussion

In this survey of RTs in North Carolina, 68% of RT respondents reported providing intubation, representing 81 unique institutions. Respondents who intubated were more likely to be from community hospitals, and these institutions were similar in size to centers that did not intubate. The median number of intubations required to be certified was 5, with 76% reporting that ≤ 5 were required for certification. A minimum level of experience was the exception, with 86% of respondents indicating there was no minimum amount of experience required prior to intubation training. A majority of respondents defined an intubation attempt as an endotracheal tube introduced in the mouth. The vast majority of respondents indicated a high level of confidence in their intubation program.

Intubation is a high-risk, low-volume procedure that requires substantial training and skill maintenance to perform safely.^18,19 The survey yielded variable competency programs for intubation programs throughout the state. Training methods varied, with 27% of institutions requiring a written test and 38% providing written materials. Bishop et al²⁰ reported that a high score on a written test was highly correlated with skill demonstration, whereas the number of intubations performed each year was not. Completing a minimum number of intubations was the most common recertification method reported by our respondents. The median reported number per year was 3, or an average of one intubation every 4 months. Only 51% of respondents reported that classroom training was part of their training. For those who did have classroom training, the median length was only 4 h, and didactic topics (eg, pharmacology, video laryngoscopy) were not reported to be consistently covered.

Although the specific number of intubations required to gain competence is currently unknown, available data suggest that the number of intubations required to achieve competence for direct laryngoscopy may be as high as 150 intubations.²¹ A systematic review found that at least 50 intubations were required by learners using direct laryngoscopy in the operating room before a success rate of 90% was achieved.²¹ Although that study did not include RTs, the majority of learners in the reported studies were novices, and the results are likely applicable to RT learners. In comparison, during training, Bucher et al²² reported that emergency medicine residents averaged 29 intubations per year (with one resident performing 157 intubations in 1 y), which is much higher than the number of intubation opportunities provided to RTs. Je et al²³ reported that 74 intubations were needed for emergency medicine residents to achieve proficiency. A study of pediatric critical care fellows found approximately 51 intubations were required to achieve competence.¹⁰ Studies evaluating the number of intubations needed for competency have largely been performed in the operating room under controlled circumstances for both paramedic and medical students, but those studies did not include RTs.²¹ The number of intubations required for RTs to achieve competence is currently unknown; the largest case series to date required 10 supervised intubations and 8 h of classroom training, thresholds few of our respondents met.⁶ Importantly, this study predated the use of video laryngoscopy and did not perform subgroup analysis evaluating the safety of RTs providing intubation in trauma, children, neonates, or other specialty situations. This is a critical area for future research to ensure RTs who perform intubations have received adequate training and skill maintenance.

RTs reported frequently intubating during emergencies outside of the operating room. During emergencies, best practice suggests that only adequately trained personnel intubate, regardless of specialty.²⁴ Only 9% of our respondents reported that the most experienced person performed intubations; however, 57% reported that any airway-certified RT made the first intubation attempt. Since our respondents indicated a high level of confidence in their RT intubation programs, it appears that the majority of respondents believed they had a competent person make the first attempt. Because time to intubation and the amount of time that chest compressions are interrupted both decrease with increasing intubation experience, having the most experienced personnel intubate should be strongly considered, although it may not be always be feasible due to a host of circumstances.²⁵

RT intubation success rate and first-attempt success rate during chest compressions have not been published to date. Video laryngoscopy has also been described because it may improve first-attempt success rate, although this relationship is unclear and its use has not been studied in RTs.^12,14,26,27 Given that 63% of respondents reported covering video laryngoscopy during their training, it appears that video laryngoscopy may not be widely utilized by RTs. We did not ask about video laryngoscopy use or other equipment specifically, in the interest of keeping the survey at a manageable length.

An important aspect of future studies is consensus on what constitutes an intubation attempt. For example, 48% of our respondents defined an attempt as an endotracheal tube being passed through the mouth. This is in direct contrast with published data that states a laryngoscope or other tool in the oropharynx defines an intubation attempt.^{8,9,12,21,26,27} To design future studies, agreement on what constitutes an attempt and controlling for individual training and experience are critical aspects to ensure a successful trial. Further data evaluating RT intubation practices are needed to identify quality improvement targets, optimize training methods, and provide higher-quality evidence supporting the role of RTs in providing intubation. Quality assurance and continuous quality improvement efforts are a critical part of any airway management program. We had responses from 7 managers, of whom only 4 had quality assurance processes in place. Combined with results from our prior data, in which only 57% of departments were engaging in quality assurance processes, there is a great opportunity for RTs to apply quality improvement methodology to intubation practice.⁴ Given the low number of responses from manager/directors, the rigor of current quality assurance processes could not be evaluated. A curriculum of twice monthly high-fidelity simulation in small groups as described by Mosier et al¹⁸ has the potential to be used as a model because they reported a significant improvement in critical care fellows intubation success rates. Importantly, over time they increased fellows’ first-attempt success rate to 90%.¹⁸

There are many limitations to our study. The respondents likely had special interest in intubation. The response rate was low, although respondents represented 81 unique institutions. As with all surveys, some questions may not have been worded clearly. There was a low number of manager/director responses, making comparison of success rates and complication rates across centers difficult. This study outlines intubation practices utilized in only a single state; a larger study is needed to determine RT intubation practices across the United States and internationally. This survey could potentially be used as a guide for future and larger studies.