On a cool fall evening, an ambulance and engine company are dispatched to assist a 44-year-old male who is having difficulty breathing. The dispatcher reports that the patient has a history of asthma. The ambulance is staffed by an EMT and a paramedic, and all members of the engine company are EMTs. On arrival, they find the patient seated on a couch in the living room with a nebulizer treatment under way. The crew immediately realizes that the patient is extremely fatigued and respiratory failure is imminent.
The sole paramedic on scene reacts quickly and begins administration of 100% oxygen and changes the patient’s room-air-driven nebulizer to an oxygen-driven nebulizer. He begins to administer levalbuterol (Xopenex) and ipratropium (Atrovent). However, the patient’s condition worsens, and the EMTs find it necessary to begin to assist respirations with a bag-valve-mask (BVM) device.
The paramedic opens the airway bag and prepares to intubate the patient. An 8.0 mm endotracheal (ET) tube is selected and removed from the packaging, and the cuff is checked and readied. The patient is moved to the floor and mechanical ventilation continued. Finally, when ready, the paramedic positions the patient and inserts the laryngoscope. The patient starts to gag and reaches for the paramedic’s hand. The paramedic grabs the ET tube and inserts it into his airway. He then holds the tube in place, inflates the cuff, and the EMTs remove the mask from the BVM and begin ventilating through the ET tube.
Immediately, vomitus fills the tube and begins to leak out. The paramedic quickly deflates the cuff and removes the ET tube. The mask is replaced on the BVM unit, and the patient is ventilated for approximately one minute. Then, the paramedic selects a second ET tube, prepares it and makes a second attempt to intubate the patient. As soon as the tube is placed, EMTs again remove the mask from the BVM and begin ventilating the patient through the ET tube.
An EMT listens over the chest and abdomen with a stethoscope. He says he hears breath sounds over the chest but doesn’t say anything about the presence or absence of breath sounds over the abdomen. An ECG monitor with capnography is attached to the patient. The EMT operating the monitor is unsure how to set the device to measure waveform capnography.
Approximately a minute later, the EMT states, “There’s something wrong with the monitor.” The paramedic quickly checks the monitor and re-checks placement of the ET tube. He says, “Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.” The patient is then moved to the ambulance and transported to St. Joseph Hospital with mechanical ventilation continued.
On arrival in the emergency department (ED), one of the emergency physicians on duty immediately evaluates the patient and checks for breath sounds. He doesn’t hear breath sounds over the chest but does hear gurgling sounds over the stomach. He grabs a laryngoscope and visualizes the larynx. He observes that the ET tube is in the esophagus. He then immediately deflates the cuff, removes the tube and suctions the airway. Mechanical ventilation is again resumed with a BVM.
The physician reaches for a new ET tube and intubates the patient. As soon as the tube is placed, he inflates the cuff and begins ventilating the patient. The patient’s color rapidly improves, and breath sounds are heard over the chest. The capnography sensor is applied, and a waveform is immediately observed on the monitor, indicating proper placement of the ET tube. By this time, however, the patient is in cardiac arrest.
Resuscitative efforts are started and continued for approximately an hour. Multiple medications and other treatments are administered. However, the patient fails to respond and is pronounced dead approximately 57 minutes after arrival at the ED.
The physician completes an EMS risk-management form documenting the improper placement of the ET tube and has it faxed to the EMS system’s medical director. After receiving this, the medical director schedules remedial education on airway management for the paramedic on the call. The monitor used on the call is taken out of service and evaluated by a manufacturer’s representative. It’s found to be functioning normally.
Approximately six months later, the paramedic, the EMS system medical director and the EMS service receive notice that they’re being sued for medical negligence by the family of the patient. During the discovery process, it’s learned that the respiratory therapist on duty when the patient arrived at the ED was a friend of the patient’s family and revealed to them that the prehospital ET tube was improperly placed by the paramedic and this led to the patient’s death.
The legal process moves slowly, and approximately one year after the patient’s death, depositions begin. During the paramedic’s deposition, it’s revealed that he had only performed one intubation on a human patient during paramedic school. Since graduating from paramedic school approximately two years prior to the incident, he has attempted intubation on a total of five patients with only three successes. His paramedic instructor from the local community college is subpoenaed and, during his deposition, reports that it was very difficult for his students to gain access to local hospitals to practice intubation, explaining that students simply learned the procedure on manikins.
Expert witnesses for the plaintiff point out that the paramedic’s care fell below the expected standard of care of a prudent paramedic. They feel that his paramedic education program, specifically as related to airway management, was inadequate. They also feel that the EMS system medical director was negligent in allowing the paramedic to practice with such a limited education, and they argue that the EMS system was negligent in not properly assessing and monitoring the capabilities of paramedics before authorizing the performance of such high-risk skills as intubation.
Finally, almost two years after the patient’s death, the case is set for trial. Approximately two weeks prior to trial, the EMS system’s insurance company agrees to settle the case for $2.4 million. Fortunately, as part of the settlement agreement, the plaintiffs agree to drop the paramedic and the medical director from the lawsuit. But, after the case is settled, the EMS regulatory agency for the state opens an investigation and subsequently finds that the paramedic and the EMS system failed to maintain an acceptable standard of care, and both are fined.
Dr. Bledsoe: If you’ve been around EMS for some time, as most of us have, you’ve probably encountered or heard about a case such as the one described here. For many years, we didn’t critically look at the success rates and outcomes related to prehospital endotracheal intubation (ETI). However, over the past decade or so, numerous studies have brought scrutiny to this long-established prehospital practice.
I know that there’s been some discussion as to whether paramedics should be allowed to continue to perform ETI in the prehospital setting. Any talk of limiting a paramedic’s skill set generates an emotional response from EMS providers and others. However, we must react to evolving science and change practices accordingly to ensure the safety and wellbeing of the patients we serve. Thus, this begs the question: Should prehospital ETI remain a core paramedic skill? Dr. Wang, you’ve been one of the foremost researchers in the area of prehospital ETI. Should paramedics continue to intubate?
Henry Wang, MD, MS: Yes, but it’s important to remember that the clinical goal is airway management—not just placing an ET tube. ETI is just one method of attaining airway management. Other methods, such as the Combitube, King airway and LMA, are also quite effective. And don’t forget CPAP, which can sometimes prevent the need for intubation. The optimal approach to the airway depends upon the patient, the clinical scenario and the skill level of the paramedic. No single “silver bullet” covers all possible scenarios. Paramedics should learn to utilize a range of airway management techniques and should learn to tailor their airway management approaches for a wide range of clinical scenarios.
William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them.
David K. Tan, MD, FAAEM, EMT-T: This is a question that simply cannot have a binary “yes” or “no” answer. ETI should remain a core paramedic skill, but medical directors, administrators and receiving hospitals have to view it in a totally different context than how we’ve historically viewed it. If a crew brings a critical patient to the hospital who ordinarily requires ETI but is being bagged instead, or has an alternative airway in place, the hospital staff often berates the crew for not establishing an airway, or they make comments assuming they were unable to intubate the trachea or that it was difficult.
Definitive airway management in the form of ETI should be done when the circumstances allow for its appropriate use, but our paramedics must be given the ability to make a decision on when alternative airways would be reasonable to either expedite transport or to do more important actions, such as perform effective chest compressions. This puts the burden of airway management education on medical directors and their instructors to ensure their crew members understand just how and when ETI should be performed and when other options would be acceptable.
Darren Braude, MD, MPH, FACEP, EMT-P: Yes, for now, ETI should remain a core paramedic skill because there are a few patient groups for whom an extraglottic airway is not ideal (e.g., anaphylaxis, neck trauma, inhalation burn, etc.) and for rural areas and critical care transport.
Marc Eckstein, MD, MPH, FACEP, EMT-P: At this time, more research is needed before we decide to abandon ETI. We need to spend more time focusing on comprehensive airway management rather than simply placing ET tubes. There are many retrospective studies that tend to show negative results when comparing critical patients who were intubated in the field versus those who had respirations assisted via bag-valve mask. These studies all suffer from similar methodological flaws, namely the fact that they’re retrospective and also that, despite trying to control for several variables through statistical analyses, often the patients who were intubated tended to be sicker than the BVM patients.
On the other hand, the prehospital intubation studies that reported “positive” results usually used successful intubation as the primary endpoint. In other words, if the ET tube was successfully placed, then the results were “positive.” This is particularly the case with rapid sequence intubation (RSI) studies. Of course the real problem with this is that successfully placing an ET tube doesn’t necessarily mean that the patient had a better outcome as a result. Those few studies that have some control group, such as the San Diego RSI study, actually found that patients who had RSI in the field had almost a 40% higher mortality rate than the BVM group (using historical controls).1
The take-home point here is that we need prehospital research that involves prospective randomized controlled trials (RCTs) with meaningful outcome variables, which are decreased morbidity and mortality. The Resuscitation Outcomes Consortium (ROC) trials are a great start, but I would like this template to really evaluate such basic issues as prehospital ETI before we evaluate new therapies, such as impedance threshold devices or hypertonic saline.
Dr. Bledsoe: I think we’re in agreement here that there remains a role for prehospital ETI, but we overemphasize ETI over ventilation. Given this, what are the major issues in EMS in regard to prehospital ETI?
Dr. Braude: The major issues are that we’ve come to associate airway management with the ET tube and in some cases we’re killing patients because of this fixation. We need to look past any one device or skill and look at patient outcomes.
Dr. Wang: Two things come to mind: “ETI tunnel vision” (the mistaken idea that ETI is the best and only way to manage the airway) and lack of adequate educational resources for ETI education—a big problem in some areas.
Dr. Tan: The major issue in prehospital ETI isn’t whether paramedics can learn to perform this procedure as was previously thought. We now know from multiple prehospital airway papers that the question is whether they’re able to retain this skill. In many agencies, paramedics simply don’t get enough opportunity to maintain this low-frequency/high-risk skill. Having a required number of ETIs per year is a start. But when many of these are on a manikin, it just isn’t enough. Also, these intubation “experiences” are often in an operating room setting under ideal conditions or in a classroom setting with manikins at table height. How about putting them on the floor? In mud? Wedged between two pieces of furniture? These are the conditions we expect our paramedics to perform in, yet we don’t often offer such experience in training.
Mr. Gandy: The biggest problem is inadequate training and practice in airway evaluation, such as using the Malampatti or Cormack & Lehane criteria; using aids to intubation, such as bougies; the BURP maneuver; alternative laryngoscope techniques, such as the “skyhook” technique; and a good assortment of alternative airway devices, including either GlideScope or AirTraq. Ventilation should be emphasized over intubation, and extensive practice with BVM ventilation should be required.
Dr. Bledsoe: Are the alternative airway devices (e.g., King LT, etc.) good enough for prehospital airway management?
Mr. Gandy: Yes. The studies have shown that excellent ventilation can be achieved with these devices.
Marvin Wayne, MD, FACEP, FAAEM: Although these alternative airway devices are pretty good, we often forget about adjuncts that enhance the success and utility of ETI. For example, in a recent study we published, we found the GlideScope video laryngoscope made ETI easier as it didn’t require complete alignment of the three axes of the airway.
Dr. Wang: Supraglottic airways are important parts of the prehospital airway tool kit. No one device is good enough.
Dr. Eckstein: These alternative airway devices, particularly the King airway, can be placed quickly, and they provide good oxygenation and ventilation. However, they don’t protect against aspiration, which of course is a major concern with emergency airway management, especially in the field. Some systems are adopting these devices as the primary airway for cardiac arrests and major trauma patients, and they seem to be rather effective. I think they may be the best approach for these two scenarios. In addition, the King airway may be placed without manipulating the cervical spine and delaying on-scene time for trauma patients.
Dr. Bledsoe: Do you feel there’s a role for RSI in the prehospital setting? Dr. Wayne, I know your program has decades of success with RSI. What do you think?
Dr. Wayne: Although there are no nationally defined indications for the use of RSI in the field, we at Whatcom Medic One believe that RSI is indicated for any patient in whom there’s a need to control an “uncontrolled” airway. This may include depressed GCS score, excess secretions, hypoxia that may be correctable, ventilatory fatigue or central nervous system depression with or without secondary respiratory depression.
Dr. Tan: I believe there is, but it must be in the right context with requisite oversight and extraordinary training. I oversee more than 100 paramedics in my system, yet only 10 of them have RSI privileges. They’re required to obtain critical care certification, attend ongoing training sessions with me every 12 weeks, attend annual specialized training courses and undergo 100% audits of their critical care trips. It’s a strenuous and time-consuming process but one that can’t be overemphasized given the complexity and danger inherent to RSI. I certainly don’t believe RSI should be a “routine” part of any standing orders, as there is nothing routine about it.
Dr. Wang: I think RSI should be restricted to the aeromedical setting for use by critical care flight nurses and/or flight medics for the reasons I’ve previously detailed. I really challenge those medical directors who currently allow RSI and promote its use in other systems. Although I applaud their efforts and attention to quality improvement and training, they still equate successful intubation with a positive outcome. As Dr. Eckstein said, in the absence of prospective RCTs, we can’t assume that prehospital RSI has actually improved outcomes for our patients.
Dr. Eckstein: RSI is potentially useful where paramedics have exceptional skill, training and medical oversight. Unfortunately, this is a tiny fraction of EMS agencies. If we replaced the “I” (intubation) with “A” (airway—Combitube, King, etc.), this might relieve much of the angst over prehospital RSI.
Dr. Bledsoe: So, as the science stands today, what subset of EMS patients benefit from prehospital ETI?
Dr. Wang: Traumatic brain injury—if the ETI and ventilation are done properly.
Dr. Eckstein: Patients with upper airway compromise (e.g., those with stridor from angioedema, allergic reactions or smoke inhalations and burns) may benefit from prehospital RSI, because they may lose their airway very quickly by the time they arrive at the ED.
Dr. Tan: The most obvious group of patients that would most likely benefit from prehospital ETI are those patients for whom passive airway management has failed. When you’ve got patients who remain hypoxic after passive techniques, such as oxygenation or CPAP, then more aggressive steps likely need to be taken, especially if they begin to exhibit altered mental status or coma. Also, those patients in whom airway protection is a major concern would probably benefit from definitive airway management with ETI assuming the sum totality of the circumstances makes such a procedure appropriate.
Dr. Bledsoe: That said, which prehospital patients probably don’t benefit from prehospital ETI?
Dr. Wang: Cardiac arrest.
Dr. Bledsoe: Probably pediatrics.
Mr. Gandy: Those classified as “difficult intubations” who can be adequately ventilated by other means.
Dr. Bledsoe: What will prehospital airway management look like in five years? Certainly, the increasing use of ketamine as an analgesic/sedative agent will change the face of things—especially trauma.
Dr. Eckstein: I agree. I think the routine use of ketamine to control the multitrauma patient will eventually replace RSI. I hope we have good scientific data to support our practices. Evidence-based medicine has never been more needed than now, particularly with regard to prehospital airway management.
Dr. Wang: I think there will be a decreased emphasis on ETI and a strong shift toward primary alternate airway use.
Dr. Braude: Bryan, let me tell you what it won’t look like—a metal laryngoscope handle and blade. There will be far more use of extraglottic airways and video laryngoscopy with little in between.
Mr. Gandy: With the advent of devices, such as the GlideScope Ranger and the AirTraq, and further development of adjuncts to intubation and alternative (supraglottic) airways, medics will have an improved arsenal of tools for airway management. However, if services don’t provide those tools together with training and education in their use, prehospital ETI will continue to fall under scrutiny and criticism. Airway management is the most important part of any critical patient’s care, yet only a fraction of the time in most training programs is devoted to it. We must either make a commitment to adequate training or find another model for airway management than ETI.
Dr. Tan: I think there will be more utilization of video laryngoscopy to enhance the success rates of prehospital RSI. We’ll also see an increased usage of supraglottic airways—especially in cardiac arrest.
Dr. Wayne: I agree with Dr. Tan. I believe that video laryngoscopy is a significant advance. Non-line-of-sight intubation may be the technique of the future for both in-hospital and out-of-hospital intubation.
Dr. Bledsoe: Henry, Darren, Marvin, Marc, David and Gene, thanks so much for sharing your thoughts and expertise on this important issue. I’m looking forward to forthcoming studies on prehospital ETI. This is certainly an evolving area of EMS. As textbook authors, we’re sometimes asked to look into the future when we write, and the discussion here will certainly help in this endeavor. Thanks again. JEMS
This article originally appeared in July JEMS as “Rethinking ETI.”