Research In Airway Management

Medic One Tuesday SeriesApril 2009

Keir J. Warner, BSParamedic Training

JEMS March 2009

“When paramedics were first introduced in the 1970’s, one of the most controversial aspects of their training program was endotracheal intubation.”

JEMS March 2009

“…it was difficult to secure time when paramedic students could practice their intubation skills on live patients.”

JEMS March 2009

“…many paramedics of that era were graduated without ever having the opportunity to perform an ETI.”

JEMS March 2009

“…many paramedics of that era were graduated without ever having the opportunity to perform an ETI.”

JEMS “Is ETI the Gold Standard”

“Argues that failure to VENTILATE not failure to INTUBATE should be the gold standard.”

JEMS “What are the Success Rates”

In Florida 37% mis-placement rateNon-cardiac arrest patients 58% 1st passPediatric ETI only 78%THE BEST DATA?–Western Washington

Bulger, et al. -98.4%Wayne, et al. -95.5%

JEMS “Outcomes”

“Outcome studies in trauma patients fail to show benefit from ETI.”“…not supported by evidence…”“ETI… associated with similar or greater mortality than bag-valve mask ventilation alone.”

JEMS “OR Time & Field ETI”

“Half of paramedic training programs provide less than 16 hours of OR time.”Average of 3.7 ETI per year In another study,–67% had 2 or less ETI per year–39% had none at all

JEMS “Alternatives”

“… paramedics had alternative airways that were as good as ETI, and perhaps safer.”“…with the advent of (supra-glotic) airways that don’t require visualization of the airway, and have been found to be safe and effective, it’s hard to continue to justify continued routine ETI in prehospital care.”

JEMS “Accepting the Inevitable”

“Ironically, it is no the scientific evidence against prehospital ETI that is driving it out of EMS practice. It is simply the inability to properly educate students in… (ETI).”“ETI, will probably be a thing of the past. We must embrace the current adjunct airways…”

Why Does Medic One Intubate ?

The Medic One Rule for Training

“For us to perform an invasive procedure it must be as if a well trained physician is doing the procedure…”

ETI Success Rates

75% 75%

89%

57%

95%

55%

96.8%

49%

97.5%

44%

97.9%

1st 2nd 3rd 4th 5th 6th All OETI

CumulativeIndividual

98.3%

3rd

Anatomic Features of the Difficult Airway

Anatomic Factors Frequency

Percentage

Obese 25 20.8 %

Anterior Trachea 51 39.2 %

Distorting Facial Trauma 7 5.8 %

Short Neck 23 19.2 %

Large Tongue 22 16.9 %

FB/ Aspiration 32 26.7 %

Small Mouth 36 30.0 %

Stiff/Fused Neck 16 13.3 %

Problems Getting an Airway?

Difficult Airway Rescue Success

Method Attempted

# Attempte

d# Worked Success Rate

Oral ETT 130 59 45.3%

Nasal ETT 1 0 0 %

Digital ETT 7 1 14.3 %

Retrograde Intubation

17 7 41.2 %

Jet Insufflation 4 1 25.0 %

Cricothyroidotomy 11 10 90.9 %

Airway Management Goals

Provide OXYGENATION (High Flow O2)–Prevent HypoxiaProvide VENTILATION (Remove CO2)

PROTECT the airway!–Aspiration–Obstruction

Airway Management Options

BLS–Spontaneous Respirations

High Flow O2 with NRB–May provide adequate Oxygenation, but what about Ventilation?

–No RespirationsBVM with Oral AirwayCombitube/LMA–No Protection from Aspiration–Poor ability to ventilate

Airway Management Options

ALS–Protect, Oxygenate & Ventilate!–Oral Endotracheal Intubation

RSI with meds for GCS <8Monitor SpO2 for Oxygenation

No reliable way to judge ventilation in the multiply injured patient

Gold Standard RSI Monitoring: Pulse Oximetry & Expired CO2

Prevent De-saturations During RSICapnography

Confirm the ETT, and monitor

Paramedic Training for Proficient Prehospital

Endotracheal Intubation

Keir J. Warner BSDavid Carlbom, MD

Colin R. Cooke, MD, MScEileen M. Bulger, MD

Michael K. Copass, MDSam R. Sharar, MD

UWSOM PMT Program

2,200 hrs of PMT–400 hrs of lectures–100 hrs of labs–600 hrs of clinical–800 hrs of field internship–300 hrs of formal evaluation

ObjectiveThe goal of this study is to

describe the relationship between the number of ETI experiences during initial

paramedic student training and the likelihood of success on subsequent ETI attempts

in the prehospital setting

Methods

A Retrospective Study UWSOM Paramedic Training ProgramReviewed Prehospital “Blue Sheets”Data into a database and analyzedINCLUSION CRITERIA–Student Attempted Prehospital

Intubation

DefinitionsETI success was defined as any

placement of an ETT that was confirmed to be within the

trachea regardless of number of attemptsFirst pass success was defined

as placement of an ETT within the trachea on the first

ETI attempt

ResultsTable 1 N=56 Students

ETI Location N=Student ETIs

Median(IQR)

Operation Room (Adults) 706 13 (11-14)

Emergency Department 71 1 (0-2)

Operating Room (Children) 263 5 (3-6)

Prehospital 576 10 (7-13)

Total Intubations 1616 29 (25-33)

ETI= Endotracheal Intubation, IQR= Interquartile Range

Results

Table 2

ETI Type N=Percent of

Prehospital ETIs

ETI Per Student

Median (IQR)

Total Success

Rate

1st Pass Success

RateCardiac Arrests 175 30.4% 3 (2-4) 88.6% 63.4%Trauma 148 25.7% 3 (1-4) 87.8% 63.5%RSI 375 65.1% 6 (5-9) 88.3% 67.7%

100%

90%

80%

70%

60%

50%0 5 10 15 20

Overall Success

First Pass Success

Cumulative Prehospital Intubation

Pre

hosp

ital E

TI

Suc

cess

Rat

e

Limitations

Inability to record all OR intubation success ratesOnly three years worth of dataMissing data on anatomic confounders

Where do we go from here?

Continue to track skill acquisition in the OR and Field settingsIncrease opportunities for ETI during trainingContinue to review and change our practices based on our evidence

ConclusionsOdds of endotracheal intubation

success increase with each cumulative exposure to ETI.

First-pass placement of the endotracheal tube with high success rates requires high numbers of ETI that may exceed the number available in many training programs.

The national curriculum recommendation of five successful endotracheal intubations is inadequate to produce appropriate prehospital ETI success rates and should be reconsidered.

Thanks

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