Anyone who’s ever been to an EMS conference and taken a stroll through the exhibit hall knows that there are more airway devices than beads on Bourbon Street. And, if you haven’t been to one of these conferences, you’ve likely seen or read about them, or in many cases, used more than one advanced airway device. The question is, which is being used more often? The ET tube or alternative airways?
Myth: With all the advanced airway choices, the endotracheal (ET) tube is becoming IS obsolete.
What We Know
One of the hottest debates right now is over whether EMS professionals should be intubating patients in the prehospital setting.
Just the thought of the big wigs taking intubation away from us might torque you off a bit, especially because some current research says EMS professionals do a great job of intubation. On the flip side, just the same amount of research (or more) says we’re not doing it well at all.
Thankfully, some have recognized that the prehospital environment is unpredictable and shouldn’t be compared to the hospital setting. One word of advice from us Mythbusters is, when reading research, always keep in mind the study limitations and the fact that nothing is proven until multiple studies conducted in similar ways show the same thing.
With all that said, we decided not to look into the best option of intubation, but rather what’s being used more in the field. In order to do that, let’s take a look at some data from the 2009 NREMT Paramedic Practice Analysis. This is a study that the National Registry does every five years to get an adequate understanding of what you, the EMS professional, are truly doing in the streets. This year, 645 nationally certified paramedics answered the survey, and with the answers they provided, we’ll try to bust this myth.
We first wanted to figure out which airway adjuncts EMS professionals have been using over the past year. We asked paramedics to report the frequency of direct intubation with an ET tube and found that 96% of paramedics reported performing ET intubation in the past year.
We also asked paramedics to report the frequency with which they used an alternative advanced airway device. Overall, 85% of study participants reported using an alternative airway device at least once over the past 12 months.
When we dug a little deeper, we found that within the past year, 72% of paramedics have used the Combitube, 43% have used the King LT, and 23% have used the LMA.
For those paramedics who haven’t intubated a patient using an ET tube in the past year, we wanted to know if they were just not intubating or using only advanced alternative airways instead?
Well, out of the 4% of paramedics who reported not intubating with an ET tube, 59% of them reported using an advanced airway device in the past year. Interestingly, 86% of paramedics reported using both the ET tube and advanced airway devices.
Next we asked, who’s using the ET tube more? To answer this, we looked at service type, years of experience and community size. As shown in Table 1, using an ET tube wasn’t dependent on the type of service (p=0.77). At least 95% of individuals in fire systems, county and municipal (or third service), private ambulances and all other services reported using the ET tube. Likewise, when inquiring about the use of other advanced airway devices, we found that, although lower proportions reported their use compared to ET tubes, the percentage using advanced airway devices was similar throughout all types of service.
Table 2 shows the frequency of intubation based on years of experience. We picked this variable to discern whether more years on the job related to use of the ET tube versus other advanced airways. As you can see, the use of both was common in all experience categories.
When looking at the statistical significance for each, we found that experience isn’t statistically related to the use of the ET tube versus other advanced airways (p=0.320 and p=.137, respectively).
Finally, Table 3 looks at community size. We defined a small community as having a population less than 25,000 and a large community as consisting of 25,000 or more people. Again, there was no difference with use of the ET tube or other advanced airways based on the community size (p=0.48 and 0.39, respectively).
What We Don't Know
As always, our data reflects only EMS professionals who are nationally certified. The question is, do nationally certified EMS professionals differ from state certified EMS professionals? Because this study included individuals from every state, it’s unlikely that practice patterns differ greatly between nationally certified EMS professionals and state certified EMS professionals.
Further, remember that we’re looking at self-reported data obtained from a survey. This data may not be as reliable as pulling information from run sheets or directly observing how often paramedics are intubating in the field.
As mentioned in the beginning, current research is questioning the efficiency and accuracy of prehospital intubation. We can’t put our two cents in with this Mythbusters column, because we have no data supporting whether each intubation, regardless of type of tube, was a success or an epic failure. So, for all you EMS researchers out there, this case isn’t closed. There’s still a need for further research in this area of prehospital care delivery.
The reported use of ET tube is still higher than the reported use of alternative airway devices. JEMS
Melissa Bentley, BS, NREMT-P, is a research fellow at the National Registry of EMTs and is pursuing her master’s in public health. She’s been involved in EMS for three years.
Antonio R. Fernandez, MS, NREMT-P, is a research fellow for the National Registry of EMTs. He’s currently pursuing a PhD in public health. Fernandez also has experience providing prehospital as well as in-hospital patient care as an EMT-B and a paramedic in urban settings.
This article originally appeared in May 2010 JEMS as To Tube or Not to Tube?: Which tube is the question.