Is aspiration considered a part of failed intubation?

Aspiration as Part of Failed Intubation

Aspiration is not considered a part of the definition of failed intubation, but rather a potential complication that may occur during or after a failed intubation event. According to current guidelines, failed intubation is specifically defined by unsuccessful attempts at placing an endotracheal tube, typically after 2-3 attempts, while aspiration is a separate complication that may result from the failed intubation scenario 1.

Definition of Failed Intubation

Failed intubation is clearly defined in airway management guidelines:

• Generally defined as three unsuccessful intubation attempts or two unsuccessful attempts at laryngoscopy 1
• In the ICU setting, failed intubation occurs in 10-30% of patients 1
• It is specifically a technical failure to place the endotracheal tube in the trachea

Relationship Between Failed Intubation and Aspiration

While aspiration is not part of the definition of failed intubation, there is an important relationship between them:

• Aspiration is a recognized complication that may occur during failed intubation scenarios 1
• It is listed as a "moderate complication" of the intubation procedure in critical care guidelines 1
• The risk of aspiration increases significantly when intubation attempts fail, particularly with multiple attempts

Airway Management Algorithms and Aspiration Risk

Guidelines specifically separate the concept of failed intubation from its potential complications:

• In the Difficult Airway Society (DAS) guidelines, aspiration is identified as a risk during failed intubation scenarios, but not as part of the definition 1
• The "can't intubate, can't ventilate" (CICV) algorithm focuses on preventing hypoxia and aspiration as consequences of failed intubation 1
• Second-generation supraglottic airway devices (SGAs) are recommended during failed intubation precisely because they provide some protection against aspiration 1

Critical Care Considerations

In the ICU setting, where aspiration risk is often higher:

• Failed intubation is defined by unsuccessful attempts, not by the occurrence of aspiration 1
• Aspiration is listed separately as a complication that may occur during intubation attempts 1
• Guidelines recommend specific strategies to minimize aspiration risk during failed intubation scenarios, such as:
  • Use of second-generation SGAs with gastric drainage ports 1
  • Proper cricoid pressure application and release when appropriate 1
  • Consideration of rapid sequence induction techniques in high-risk patients 2

Conclusion

While aspiration is a serious and potentially life-threatening complication that may occur during or after failed intubation, it is not part of the definition of failed intubation itself. Failed intubation refers specifically to the inability to place an endotracheal tube after multiple attempts, while aspiration is a separate adverse event that may result from this situation. Understanding this distinction is critical for proper implementation of airway management algorithms and for accurately documenting and analyzing airway-related adverse events.