Columns, Training

Training, Practice, Research Lead to Successful Airway Management

Issue 3 and Volume 40.

Improving Intubation

Lockey DJ, Healey B, Crewdson K, et al. Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. Dec. 23, 2014. [Epub ahead of print].

First and foremost, we’d like to congratulate JEMS on 35 years of quality EMS reporting. We’re honored and privileged to be part of this monthly,
ground-breaking publication.

Coming to us from the British Journal of Anaesthesia, David Lockey, MD, and associates set out to determine the demand for on-scene advanced airway interventions in London, U.K. In a one-year prospective observational study, they asked enhanced care teams (ECTs) to document airway compromise on arrival.

Research: ECTs were dispatched to serious trauma cases automatically or by request of the first arriving paramedic crew. Comprised of a physician and a paramedic, ECTs had additional airway management training, responded by helicopter or rapid response vehicle, could perform rapid sequence intubation (RSI) and assumed care once they arrived.

The ground paramedic crews in this system didn’t have any additional advanced airway training. They had access to standard basic airway adjuncts, laryngeal mask airways (LMAs) and iGels, and those registered before 2010 could perform non-pharmacologically facilitated endotracheal intubation (ETI).

ECTs attended to a total of 1,963 patients during the study period. Out of these cases, 472 (24%) patients required advanced airway management and were intubated. Of these patients, 469 (99%) were attended to by ground ambulance personnel before an ECT arrived, with 269 (57%) of these patients having an airway compromise on arrival of an ECT.

Of these 269 airway comprised patients, 16 (6%) had a full airway obstruction and 158 (59%) had a partial airway obstruction, with a vast majority of these patients’ airways contaminated with blood or vomit. Of the remaining 200 patients (43%) who didn’t have a compromised airway on ECT arrival, 134 (67%) patients received some kind of airway intervention by a ground ambulance crew—94 patients (70%) were given advanced airway management. There were 29 successful ETIs out of 45 attempts (64% overall success rate) and it should be noted that 27 of the 29 successful ETI attempts (93%) were during cardiac arrest cases.

ECTs had a 100% overall success rate at airway management, and corrected seven esophageal intubations (EI) on their arrival (five unrecognized and two recognized, but not yet corrected). Forty eight out of 52 (93%) LMAs or iGels attempted by ground ambulance crews were successful.

Discussion: ETI remains a hot topic in our industry. Unfortunately, passionate critics and advocates have little research to base their arguments. While we applaud these researchers for tackling the topic, the relative degree of airway compromise isn’t known and the assessments by ECTs are subjective and open to bias. Additionally, the amount of time between ambulance arrival and ECT arrival isn’t accounted for.

With that said, this is a significant sample of trauma patients who required airway management, and a 64% success rate with seven EIs by ground paramedics is concerning. The authors note that unsuccessful intubations were performed by paramedics who didn’t possess as much training or don’t regularly perform RSI.

A recent study performed in Seattle showed a 77% first attempt and 99% overall intubation success rate by paramedics using RSI.1 The authors of this study suggest a multitude of similar factors affecting success, including special training, frequent use of the skill and teamwork.

Both studies show an increased need for additional research on training, the review of causes behind failed intubations and how additional tools, such as sedatives and paralytics, can dramatically increase ETI success rates.

Reference

1. Prekker ME, Kwok H, Shin J, et al. The process of prehospital airway management: Challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42(6):1372–1378.

Bottom line

What we know: Intubation by paramedics has fallen under great scrutiny in recent years.

What this study adds: Advanced airway management is paramount to survival of trauma patients. Advanced training, teamwork, continuous quality improvement and drug-facilitated intubation can greatly increase success in the field.