What happens with failed blind nasal tracheal intubations?

INTRODUCTION: Flight nurses and paramedics may be called on to perform a blind nasal tracheal intubation (BNTI) as an airway management adjunct. A literature review found two publications addressing air medical BNTI failure rates. No studies examining demographic factors associated with BNTI failure rates nor published reports evaluating the failure rates of subsequent oral tracheal intubation (OTI) and cricothyroidotomy (cric) attempts after failed BNTI were found. This study was undertaken to identify factors associated with BNTI failure and determine the failure rates for OTI and cric performed by flight nurses and paramedics after failed BNTI.

METHODS: All flight nurses' and paramedics' BNTI attempts and subsequent OTI and cric attempts after failed BNTI during 1999 were reviewed retrospectively. BNTI, OTI, and cric success versus failure groups subsequently were evaluated by student t-test and chi-squared analysis to determine if demographic differences for age, gender, type of illness (medical, cardiac, or trauma), in-hospital versus scene, nurse versus paramedic, and rotor- versus fixed-wing transport could be found. A P value < 0.05 was considered statistically significant.

RESULTS: Thirty-six BNTIs were attempted by flight nurses (N = 34) and paramedics (N = 2). Twenty-one BNTIs were attempted at the scene of injury, whereas 15 were attempted in the hospital setting. Eleven of 36 (31%) patient attempts were unsuccessful, and all of these patients received subsequent OTI attempts. Of the 11 OTI patient attempts, two were unsuccessful (18%) and subsequently required cricothyroidotomy. Both attempted patient cricothyroidotomies were successful. Failed versus successful BNTIs were analyzed for demographic differences. Our study found that the BNTI failure (10/21, 48%) was significantly more likely to occur in younger (P < 0.001) trauma (P < 0.01) patients transported from the scene of injury (P < 0.05) by rotor-wing (P < 0.05) than in the hospital (1/15, 7%) setting. Unlike BNTIs, no significant demographic differences were observed between the failed (2/11, 18%) versus successful (9/11, 82%) OTI after a failed nasal tracheal intubation.

CONCLUSION: Flight nurse and flight paramedic teams show a rather low BNTI failure (7%) rate within the confines of the hospital setting but a significantly higher failure rate (48%) when this procedure is performed at the scene of an injury. Although not measured in this study, this difference may represent fewer insertion attempts, less time spent performing BNTI because of the need to rapidly transport trauma patients to appropriate treatment centers, or variation in technique because of the concern for cervical spine injury. Further studies are required to elucidate why differences in scene versus in-hospital BNTI success rates are occurring.