How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation?

Aim: The cardiopulmonary resuscitation (CPR) guidelines recommend that endotracheal intubation (ETI) should be performed only by highly skilled rescuers. However, the definition of 'highly skilled' is unclear. This study evaluated how much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time < 10 s) or oesophageal intubation during CPR. Methods: This was a clinical observation study using review of CPR video clips in an urban emergency department (ED) over 2 years. Accumulated ETI experience and performance of ETI were analysed. Main outcomes were 1) 'qualified ETI': successful ETI within 60 s without complications and 2) 'highly qualified ETI': successful ETI within 30 s without complications. Results: We analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI required 137 experiences of ETIs (1218 days of training). A 90% success rate for highly qualified ETI required at least 243 experiences of ETIs (1973 days of training). Conclusions: Accumulated experience can improve the ETI success rate and time to successful ETI during CPR. Because ETI must be performed quickly without serious interruption of chest compression during CPR, becoming proficient at ETI requires more experience than that required for non-arrest patients. In our analysis, more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI.