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The Disappearing Endotracheal Tube. Bryan Bledsoe, DO, FACEP Clinical Professor of Emergency Medicine University of Nevada School of Medicine . Introduction. Introduction. When paramedics were introduced in the early 1970s, ETI was a mandatory skill.
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The Disappearing Endotracheal Tube Bryan Bledsoe, DO, FACEP Clinical Professor of Emergency Medicine University of Nevada School of Medicine
Introduction • When paramedics were introduced in the early 1970s, ETI was a mandatory skill. • Prior to that, ETI was solely in the domain of physicians and nurse anesthetists.
Introduction • Eventually, paramedics were accepted into the operating room for clinical ETI education.
Introduction • Prior to the late 1980s and early 1990s, the vast majority of people who received prehospital ETI were dead or died. • Missed ETI was not that closely scrutinized because it often did not contribute to patient’s demise.
Introduction • In the 1990s there was a push to intervene earlier in the injury/disease continuum. • Trauma patients with GCS 8 should be intubated. • Medical patients in respiratory failure should be intubated.
Introductions • Paramedics were now intubations patients who had a good chance of survival. • This subsequently put the practice in a whole new light.
Introduction • Now that it mattered, it was found that paramedic ETI success rates were woefully low.
Introduction • Procedures were changed and devices were added to improve the success rate of prehospital ETI.
Introduction • Scrutiny has now moved to patient outcomes.
Gold Standard? • Is the endotracheal tube still the gold standard for prehospital care? • In certain situations, maybe yes; in other situations, maybe no.
Gold Standard? • “Endotracheal intubation is the most definitive means to achieve complete control of the airway.”
Gold Standard? • “This [ETI] is the preferred technique for managing a patient’s airway in the field setting.”
Gold Standard? • “The gold standard of airway care in patients who cannot protect their airway or those needing assistance in breathing is the endotracheal tube.” • Ron Stewart, MD
Gold Standard? • Many paramedics have graduated with the idea that failure to intubate a patient was substandard care. • In reality, failure to ventilate a patient is substandard care—not failure to place an endotracheal tube. • The difference, here, is significant.
Are Paramedics Good at ETI? • Paramedic education courses have always been rather brief when compared to other allied health professions.
Are Paramedics Good at ETI? • 1998 United States DOT Curriculum for Paramedics: • 1,000-1,200 total hours • 500-600 classroom & practical hours. • 200-300 clinical hours. • 250-300 field internship hours.
Are Paramedics Good at ETI? • Minimum required ETIs: • Anesthesiology resident: >400 • CRNA student: 200 • EM Resident: 35-200 USDOT requires a minimum of 5 intubations prior to paramedic graduation.
Are Paramedics Good at ETI? • Research has shown that paramedic students require at least 15-20 intubations to attain basic skills proficiency. Wang HE, Seitz SR, Hostler D, Yealey DM. Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9:156-62
Are Paramedics Good at ETI? • Jenkins, WA, Verdile VP, Paris PM. The syringe aspiration technique to verify endotracheal tube position. Am J Emerg Med. 1994;12:413-416 • Bozeman WP, Hexter D, Liang HK, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med. 1996;27:595-599. • Stewart RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel. Chest. 1984;85:341-345. • Sayre MR, Sackles JC, Mistler AF, et al. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med. 1998;31:228-233. • Pointer JE. Clinical characteristics of paramedics’ performance of endotracheal intubation. J Emerg Med. 1988;6:505-509.
Are Paramedics Good at ETI? Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37:32-7
Are Paramedics Good at ETI? • Maine study: • 81% success rate • 19% missed rate Jemmett ME, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med. 2003;10:961-5
Are Paramedics Good at ETI? • 132 patients intubated in prehospital setting: • 12 (9%) misplaced • 11 esophageal • 1 hypopharynx • 20 (15%) right main stem bronchus. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers, Prehosp Emerg Care. 2007;11:213-8.
Are Paramedics Good at ETI? • 1-year county-wide EMS system study: • 592 ETI attempts: • 536 (90.5%) successful intubations. • No single reason for prehospital ETT failure. • Only a small percentage of patients had a “difficult airway.” Wang HE, Sweeney TA, O’Connor RE, Rubinstein H. Failed prehospital intubations: an analysis of emergency department courses and outcomes. Prehosp Emerg Care. 2001;5:134-41
Are Paramedics Good at ETI? • Prehospital ETI often requires multiple attempts. • 1,941 cases of prehospital ETI: • >30% of patients required more than 1 attempt. • Cumulative success rate overall per attempt (for first 3 attempts): • 69.9%, 84.9%, & 89.9% • Cumulative success rate for non-arrest: • 57.6%, 69.2% & 72.7% Wang HE, Yealey DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation. Acad Emerg Med, 2006;13:372-7
Are Paramedics Good at ETI? • 1989 study of pediatric cardiac arrests: • ETI success rate: 64% • 63 pediatric patients in Milwaukee County, WI: • ETI success rate: 78% Aijian P, Tsai A, Knopp R, Jailsen GW. Endotracheal intubation of pediatric patients by paramedics, Ann Emerg Med. 1989;18:489-94. Losek JD, Bionadio WA, Walsh-Kelly C, Hennes H, Smith DS, Glaeser PW. Prehospital pediatric endotracheal intubation performance review. Pediatr Emerg Care. 1989;5:1-4.
Are Paramedics Good at ETI? • Some systems have had good ETI rates: • San Diego County: • 1 UEI/264 PEDIATRIC intubations (99%) • Seattle/King County: • 98.4% success • Bellingham, WA: • 20-year review • 95.5% ETI success rate • 0.3% UEI Vilke GM, Steen PJ, Smith AM, Chan TC. Out-of-hospital pediatric intubation by paramedics: the San Diego experience. J Emerg Med. 2002;22:71-4 Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ. An analysis of advanced prehospital airway management. J Emerg Med 2002;23:183-9. Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care 1999;3:107-9.
Outcomes • As EMS has evolved, managers and medical directors must ask, “Does this practice, procedure, or drug improve outcomes?” • If so, does cost justify benefit?
Outcomes • Multi-center study of prehospital ETI: • Overall success rate was 86.8% • There was no association between prehospital ETI and field or initial ED survival. Wang HE, Kupas DF, Paris PM, Bates RR, Yealey DM. Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intonation. Resuscitation. 2003;58:49-58
Outcomes • Prehospital ETI associated with decreased survival in patients with moderate to severe TBI. Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma. 2005;58:933-9.
Outcomes • New Orleans Study: • ETI was associated with similar or greater mortality than B-V-M ventilation alone. Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma. 2004;56:531-536
Outcomes • Pennsylvania Trauma Registry: • 4,098 trauma patients • 43.9% received prehospital ETI. • 56.1% received in-hospital ETI. • Adjusted rates of death higher for prehospital ETI (OR=3.99 [95% CI=3.21-4.93]) • Chances of poor neurologic outcome were worse for prehospital ETI (OR=1.61 (95% CI=1.15-2.26]). Wang HE, Peitzman AB, Vassidy LD, Adelson PD, Yealey DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004;44:439-450.
Outcomes • Dallas, TX study: • Prehospital ETI and positive-pressure ventilation were associated with hypotension and decreased survival. Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive-pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma. 2005;59:1140-7.
Outcomes • Oregon study: • 8,786 patients • 534 (6%)-OOH-ETI • 307 (57.5%)-OOH-RSI • 227 (42.5%)-OOH Only Cudnick NT, Newgard CD, Wang H, Bangs C, Herrington IV R. Distance Impacts Mortality in Trauma Patients with an Intubation Attempt. PrehospEmerg Care. 2008;12:459-466
Outcomes • Australia: • “Overall current paramedic airway practice in most states of Australia is not supported by the evidence and is probably associated with worse patient outcomes after severe head injury. For road-based paramedics, rapid transport to hospital without intubation should be regarded as the standard of care.” Bernard SA. Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emer Med Australas. 2006;18:221-8.
Outcomes • United Kingdom: • Best-evidence report on prehospital ETI in adult major trauma victims with TBI: • “It is concluded that prehospital intubation is associated with increased mortality in these patients.” Sen A, Nichani R. Best evidence topic report. Prehospital endotracheal intubation in adult major trauma patients with head injury. Emerg Med J. 2005;22:887-9.
Outcomes • Pediatric ETI: • RCT of 830 consecutive children < 12 years of age (or who were estimated to weigh < 40 kg). • Randomized to receive: • BVM ventilation • BVM ventilation followed by prehospital ETI. • No significant difference in survival to discharge or neurological status at discharge between groups. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283:783-790
Outcomes • Pediatric patients with severe TBI: • No survival advantage or functional advantage for patients receiving prehospital ETI when compared to those who only received BVM ventilation. Cooper A, DiScala C, Foltin G, Tunik M, Markenson D, Welborn C/ Prehospital endotracheal intubation for severe head injury in children: a reappraisal. Semin Pediatr Surg. 2001;10:3-6.
Anesthesia Practice Changes • Decreased ETI for general anesthesia due to acceptance of the LMA and similar supraglottic airways.
Decreased OR Exposure • Access to the OR has always been difficult for paramedic programs. • EMS education tends to be community based. • EMS education is shorter than similar allied health disciplines. • EMS providers in many states are not truly licensed. • CMS and third-party payers limit access to patients to “licensed providers.”
Decreased OR Exposure • University of Pittsburgh study: • Anonymous survey of 192 accredited paramedic programs. • 161 (85%) responded. • 156 (97%) of programs surveyed used OR training, but it was limited to a median of 17-32 hours/student. • Half of the programs provided fewer than 16 hours OR training. • Students attempted a limited number of ETIs (median, 6-10).
Decreased OR Exposure • University of Pittsburgh study: • 61% of programs reported competition from other health care educational programs as a reason for decreased OR access. • Other reasons: • Increased LMA usage • Medical/Legal concerns. • Of the survey group: • 33% reported a recent reduction in OR access. • 36% anticipated decreased OR access. Johnston BD, Seitz SR, Wang HE. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Acad Emerg Med. 2006;132:1051-5
Decreased OR Exposure • Psychomotor skill development: • Imitation • Manipulation • Precision • Articulation • Naturalization Students should reach this point prior to graduation