Written by Clay Smith
Prehospital Airway Management
In light of the important prehospital airway management articles that came out this week, I thought it might be helpful to go into more depth on the topic of prehospital airway management. Using the JF search tools, I found all these posts in under a minute.
Maybe Intubation is Worse In Arrest?
These two studies were not in the prehospital setting but are relevant to the discussion of intubation during arrest. In late 2016, a retrospective study of pediatric in-hospital arrest in JAMA found that survival to discharge was 36% in those intubated during the resuscitation vs 41% in those who were not. Then in early 2017, JAMA published a similar article of adult in-hospital arrest, which found survival with a good neurological outcome was better in patients not intubated in the first 15 minutes of arrest, NNT = 33.
VL or DL?
Now we get into some prehospital studies. Among less experienced, non-physician intubators, first-pass success for ETT passage almost doubled when video laryngoscopy was used compared to direct laryngoscopy.
Reason for Concern
This meta-analysis of 21 studies in mid-2017 raised concern about prehospital intubation of trauma patients. There was a marked increase in mortality among patient intubated in the prehospital setting vs those intubated in the ED, 48% vs 29%. However, almost all the included studies were retrospective. The only RCT included found no difference in mortality, a trend toward improved mortality, and improved neurological outcome with PHI, though it was not powered for these outcomes.
Later in 2017, a post-hoc look at the PROTECT III dataset (originally a multi-center RCT of progesterone in TBI patients that showed no benefit) found that, to the authors’ surprise, there may have been benefit to prehospital intubation. More patients with PHI had a favorable neurological outcome than those who were not intubated, 57.3% vs. 46.0%, p = 0.003, respectively, and “odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated.” But the groups were not well matched when stratified by PHI (rather than the initial study intent, progesterone vs placebo). 80% of those with PHI came by air; 91% without PHI came by ground. So what this study may be measuring is the beneficial effect of prehospital airway management in TBI by highly trained and skilled aeromedical personnel.
What about SGAs?
Also in mid-2017, a small retrospective study showed improved mortality and good neurological outcome of arrest patients who had a SGA placed, despite earlier concerns that SGAs might worsen outcome in arrest patients.
Just Bag ‘Em
In early 2018, JAMA published results of a RCT of bag-mask ventilation vs ETT in arrest. They found survival with a good neurological outcome at 28-days was the same in each group, 4.3% and 4.2% for BMV and ETT, respectively.
PART and AIRWAYS-2
This week, we covered PART and AIRWAYS-2. Both were prehospital EMS studies in OHCA arrest patients. PART showed improved 72-hour survival for the laryngeal tube over ETT (18.3% vs 15.4%; P = 0.04; RR 1.19) and also showed improved secondary outcomes of ROSC (27.9% vs 24.3%; P = 0.03), hospital survival (10.8% vs 8.1%; P = 0.01), and favorable neurological status at discharge (7.1% vs 5.0%; P = 0.02). AIRWAYS-2 was larger and showed no difference in good neurological recovery after non-traumatic out-of-hospital cardiac arrest (OHCA) at 30 days with use of an i-gel SGA compared to ETT. An important finding in both studies was that paramedics seemed to prefer to use a SGA first-line and often avoided advanced airway management at all when they were randomized to place an ETT. The conclusion or the main editorial was that for those in, “settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”
Tube or Not?
Prehospital intubation is an infrequent EMS procedure and difficult skillset to maintain, though it has a role in prehospital care. However, it may be harmful if attempted by those with less experience and seems best in the hands of those who perform more frequent intubation, which is often helicopter EMS crews. VL may improve success in the prehospital setting. For OHCA, PART and AIRWAYS-2 have convinced me that placing either a LT or other SGA is the best prehospital advanced airway for cardiac arrest patients. There may be other scenarios in which prehospital intubation is the right course and may be life saving, but I think it should remain infrequent. I welcome your thoughts in the comments section on the website.
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1 thought on “Prehospital Airway Management”
While I understand there are varying levels of expertise among paramedics, I have to respectfully disagree with your view.
Intubation is a critical skill. Less frequent practice of this type of skill will further reduce proficiency, which ultimately translates to a more poor outcome for patients. I believe that the key here is more strenuous training and accountability. In a busy, well trained and managed service, first pass success rate should be paramount. As far as cardiac arrest patients in the field, the variables are never ending, which can obviously warp results.
EMS is such a fractured system; for example, in Oklahoma, only 19 of 77 counties have paramedic level coverage at all. Then you have your varying blends of hospital based, fire based, and private services. It needs more oversight, alignment, progressive benchmark training and analysis. This is accomplished with medical directors who are dedicated and involved, as well as political involvement.