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Multicenter Study
. 2025 Dec 1;32(6):430-436.
doi: 10.1097/MEJ.0000000000001276. Epub 2025 Sep 5.

Association between physician specialty and first-attempt intubation success in the emergency department

Lucas Oliveira J E Silva  1   2 , Rafael Von Hellmann  3 , Bruno A M Pinheiro Besen  4 , Julia M Dorn de Carvalho  5 , Ludhmila Abrahao Hajjar  5 , Daniel Pedrollo  1 , Caio Goncalves Nogueira  6 , Natalia Mansur P Figueiredo  6 , Carlos Henrique Miranda  7 , Danilo Martins  8 , Thiago Dias Baumgratz  8 , Bruno Bergesch  9 , Diogo Costa  9 , Osmar Colleoni  10 , Juliana Zanettini  11 , Ana Paula Freitas  11 , Nicole Pinheiro Moreira  12 , Patricia Lopes Gaspar  12   13 , Renato Tambelli  14 , Maria Cristina Costa  15 , Samara Silveira  15 , Wilsterman Correia  16 , Rafael Garcia de Maria  17 , Ubirajara A Vinholes Filho  18 , Andre P Weber  19 , Vinicius da Silva Castro  20 , Carlos Fernando D Dornelles  21 , Barbara S Tabach  21 , Hélio P Guimarães  5 , Gabriela Stanzani  5 , Thiago F Gava  5 , Aidan Mullan  2 , Gabriel Petrin Alonso Silva  5 , Giovanna Cardoso de Oliveira  5 , Benjamin J Sandefur  2 , Fernanda Bellolio  2 , Julio C G Alencar  22 , Ian Ward A Maia  2   5 ; BARCO Investigators
Collaborators, Affiliations
Multicenter Study

Association between physician specialty and first-attempt intubation success in the emergency department

Lucas Oliveira J E Silva et al. Eur J Emerg Med. .

Abstract

Background and importance: Emergency airway management in the emergency department (ED) is a high-risk procedure associated with patient outcomes. First-attempt success is a widely recognized quality metric, as multiple attempts are associated with an increased risk of peri-intubation complications. In Brazil, where emergency medicine is a recently established specialty, many ED are staffed by physicians without formal emergency medicine training. The association between emergency medicine training and intubation outcomes in this setting has not been well characterized.

Objective: To assess the association of physician specialty with first-attempt success and immediate peri-intubation complications in Brazilian EDs.

Design: Secondary analysis of a multicenter, prospective cohort study from the Brazilian Airway Registry Cooperation.

Setting and participants: This study included adult patients who underwent tracheal intubation in EDs between March 2022 and April 2024. Patients were excluded if the intubation occurred outside the ED, during cardiopulmonary resuscitation, or for elective procedures. Intubations performed by medical students were also excluded. Physicians were categorized by specialty as emergency medicine or nonemergency medicine.

Outcome measures and analysis: The primary outcome was first-attempt success; secondary outcomes included peri-intubation complications (severe hypoxemia, hemodynamic instability, and cardiac arrest). Multivariable logistic regression was used to assess the association between physician specialty and outcomes.

Main results: Among 2582 patients, 1087 (42.1%) were intubated by emergency physicians and 1495 (57.9%) by other physicians (mainly internal medicine and surgery). Intubations by emergency physicians were associated with a higher rate of first-attempt success [80.4 vs. 70.9%, adjusted odds ratio [aOR]: 1.63, 95% confidence interval (CI): 1.34-1.97]. There was also a higher odds of intubations without major complications (aOR: 1.20, 95% CI: 1.01-1.42).

Conclusion: In this study, there was a higher rate of first-attempt success in intubations performed by board-certified emergency physicians compared with other physicians working in Brazilian EDs.

Keywords: critically ill patients; emergency airway; emergency medicine operations; major adverse events; orotracheal intubations.

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References

    1. Maia IWA, Besen BAMP, Silva LOJE, von Hellmann R, Hajjar LA, Sandefur BJ, et al.; BARCO group. Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study. Crit Care. 2025; 29:155.
    1. Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al.; INTUBE Study Investigators. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA. 2021; 325:1164–1172.
    1. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013; 20:71–78.
    1. April MD, Schauer SG, Nikolla DA, Casey JD, Semler MW, Ginde AA, et al. Association between multiple intubation attempts and complications during emergency department airway management: a national emergency airway registry study. Am J Emerg Med. 2024; 85:202–207.
    1. Nah S, Lee Y, Choi SJ, Lee J, Hwang S, Lim S, et al.; Korean Emergency Airway Management Society. Current trends in emergency airway management: a clinical review. Clin Exp Emerg Med. 2024; 11:243–258.

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