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The Future of the Endotracheal Tube

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  • 1. The Disappearing Endotracheal Tube
    Bryan Bledsoe, DO, FACEP
    Clinical Professor of Emergency Medicine
    University of Nevada School of Medicine
  • 2. Introduction
  • 3. 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.
  • 4. Introduction
    Eventually, paramedics were accepted into the operating room for clinical ETI education.
  • 5. 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.
  • 6. 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.
  • 7. Introductions
    Paramedics were now intubations patients who had a good chance of survival.
    This subsequently put the practice in a whole new light.
  • 8. Introduction
    Now that it mattered, it was found that paramedic ETI success rates were woefully low.
  • 9. Introduction
    Procedures were changed and devices were added to improve the success rate of prehospital ETI.
  • 10. Introduction
    Scrutiny has now moved to patient outcomes.
  • 11. IS ETI the gold standard?
  • 12. Gold Standard?
    Is the endotracheal tube still the gold standard for prehospital care?
    In certain situations, maybe yes; in other situations, maybe no.
  • 13. Gold Standard?
    “Endotracheal intubation is the most definitive means to achieve complete control of the airway.”
  • 14. Gold Standard?
    “This [ETI] is the preferred technique for managing a patient’s airway in the field setting.”
  • 15. 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
  • 16. 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.
  • 17. Have paramedics ever been good at Eti?
  • 18. Are Paramedics Good at ETI?
    Paramedic education courses have always been rather brief when compared to other allied health professions.
  • 19. 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.
  • 20. 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.
  • 21. 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
  • 22. 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
    • 23. 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.
    • 24. Stewart RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel. Chest. 1984;85:341-345.
    • 25. Sayre MR, Sackles JC, Mistler AF, et al. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med. 1998;31:228-233.
    • 26. 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
  • 27. 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
  • 28. 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.
  • 29. 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
  • 30. 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
  • 31. 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.
  • 32. 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.
  • 33. Prehospital intubations outcomes
  • 34. 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?
  • 35. 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
  • 36. 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.
  • 37. 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
  • 38. 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.
  • 39. 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.
  • 40. 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
  • 41. Outcomes
  • 42. Outcomes
    “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.
  • 43. 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.
  • 44. 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
  • 45. 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.
  • 46. Changes in general anesthesia practice
  • 47. Anesthesia Practice Changes
    Decreased ETI for general anesthesia due to acceptance of the LMA and similar supraglottic airways.
  • 48. Anesthesia Practice Changes
  • 49. Decreased operating room exposure
  • 50. 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.”
  • 51. 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).
  • 52. 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
  • 53. Decreased OR Exposure
    Psychomotor skill development:
    Students should reach this point prior to graduation
  • 54. Decreased OR Exposure
    ETI requires repetition of the skill for mastery.
    Number of reps varies with student and skill performed.
    Estimated that 100+ reps are required before cortical ingraining occurs.
  • 55. Decreased OR Exposure
    There is a relationship between increased success rate of ETI and accumulated live experience.
    Wang HE, Seitz SR, Hostler D, Yealey DM. Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9:156-62
  • 56. Increased Experience & Survival
    Evaluation of paramedics in Pennsylvania 2000-2005:
    Low (1-10 ETIs)
    Medium (11-25 ETIs)
    High (26-50 ETIs)
    Very High (> 50 ETIs)
  • 57. Increased Experience & Survival
    25,718 ETIs by 5,433 paramedics linked to patient outcomes (77.7% linkage rate):
    Low: 4,835 (18.8%)
    Medium: 9,850 (38.3%)
    High: 8,513 (33.1%)
    Very High: 2,289 (8.9%)
    Cardiac arrest: 17.4%
    Non-arrest: 68.2%
    Adjusted survival was higher for cardiac arrest patients intubated by high- and very-high-ETI-experience paramedics.
  • 58. Increased Experience & Survival
    Survival odds ratio (compared to low ETI experience) [95% CI]:
    Medium: 1.04 (0.91-1.18).
    High: 1.18 (1.01-1.38).
    Very High: 1.29 (1.04-1.61).
    Survival odds better for non-arrest patients (compared to low ETI experience) [95% CI]:
    Medium: 1.05 (0.8-1.25).
    High: 1.31 (1.07-1.38).
    Very High: 1.59 (1.21-2.10).
    Wang HE, Balasubramani KG, Lave JR, Yealey DM, Cook LJ. Paramedic endotracheal intubation experience improves survival. [Abstract] Prehosp Emerg Care. 2009;13:90-91.
  • 59. Decreased field opportunities
  • 60. Decreased Field Opportunities
    It has been generally assume that ETI and IV therapy were the most frequently performed paramedic skill.
  • 61. Decreased Field Opportunities
    The number of prehospital ETIs per paramedic per year is low.
    For most systems, the number of intubations per paramedic per year are too low for skills maintenance.
    Number of patients who require ETI not as high as thought.
    Number of providers authorized to perform ETI has increased dramatically.
  • 62. Decreased Field Opportunities
    Milwaukee, WI study:
    Average annual number of paramedics was 177.
    Each paramedic only performed 3.7  3.3 intubations a year.
    Cady CE, Pirrallo RG. The effect of Combitube use on paramedic experience in endotracheal intubation. Am J Emerg Med. 2005;23:868-871.
  • 63. Decreased Field Opportunities
    Rural state (Maine) study:
    957,836 patients encounters during 5-year study period.
    Average number of EMS providers who could perform ETI.
    5,612 total ETI attempts during the 5-year study period.
    Only a range of 37%-42% of eligible providers annually performed ETI.
    A mean of 18 providers attempted more than 5 intubations annually.
    Only 137 ETIs were pediatric.
  • 64. Decreased Field Opportunities
    Rural state (Maine) study:
    ETI success rate:
    84% in providers with < 5 annual intubations
    86% in providers with > 5 annual intubations
    Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun LE. Endotracheal intubation in a rural state: procedure utilization and impact of skills maintenance guidelines. Prehosp Emerg Care. 2003;7:352-6.
  • 65. Decreased Field Opportunities
    1-year study of 11,484 ETIs performed by 5,245 prehospital providers:
    67% performed two or fewer ETIs.
    39% did not perform any ETIs.
    Wang HE, Kupas DF, Hostler D, Cooney R, Yealy DM, Lave JR. Procedural experience with out-of-hospital endotracheal intubation. Crit Care Med. 2005;33:1718-21
  • 66. Decreased Field Opportunities
    AHA recommends that prehospital ALS providers perform a minimum of 6-12 intubations a year to remain current.
    The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2000;102(suppl 8):I87.
  • 67. Decreased Field Opportunities
    EMS systems with high ETI success rate require a minimum of 15 ETIs per provider per year.
    All but a few extremely busy EMS systems can ever achieve this level.
    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
  • 68. Decreased Field Opportunities
    High-fidelity human simulation may help the student or paramedic get ETI reps.
    It will never replace the need for supervised practice on living tissues.
  • 69. Better alternative airways
  • 70. Better Alternative Airways
    When EMS began, there was really no acceptable alternative to ETI.
  • 71. Better Alternative Airways
    First-generation airways:
    No more effective than BVM
    Esophageal rupture
    Tracheal intubation
    Bryson TK, Benumof JL, Ward CF. The esophageal obturator airway: a clinical comparison to ventilation with a mask and oropharyngeal airway. Chest. 1978;74:567-
    Scholl DG, Tsai SH. Esophageal perforation following use of esophageal obturator airway. Radiology. 1977;122:315-6
    Yancey W, Wears R, Kamajian G, Derovanesian J. Unrecognized tracheal intubation: a complication of the esophageal obturator airway. Ann Emerg Med. 1980;9:18-20.
  • 72. Better Alternative Airways
    Second-generation airways:
    ETC first alternate airway to receive significant OR usage.
  • 73. Better Alternative Airways
    Third-generation airways much better.
    Primarily supraglottic.
  • 74. Better Alternative Airways
    King LT
  • 75. Better Alternative Airways
    After introduction of an ETC airway to an EMS system, the ETI success rate fell from 93.5% to 91.6%.
    Cady CE, Pirrallo RG. The effect of Combitube use on paramedic experience in endotracheal intubation. Am J Emerg Med. 2005;23:868-871.
  • 76. Better Alternative Airways
    RCT of 52 paramedics using mannequins.
    Time to ventilation ():
    ET = 46 seconds
    LMA = 23 seconds
    Mean number of attempts to achieve ventilation:
    ET = 1.27
    LMA = 1.1
    Esophageal = 9 (17%)
    Right mainstem = 14 (27%)
    LMA malposition = 5 (9.5%)
    Chin L, Hsiao AL. Randomized trial of endotracheal tube versus laryngeal mask airway in simulated pediatric cardiac arrest. Pediatrics. 2008;122:e294-e297.
  • 77. litigation
  • 78. Litigation
    Alleged airway misadventures are still a major cause of malpractice suits.
    10-year review by one malpractice carrier:
    24 EMS claims
    10 (42%) airway-related.
    Cumulative claims from these 10 cases > 19.6 million dollars.†
    † - HPSO
  • 79. summary
  • 80. Summary
    Paramedics see skills as being an important part of their practice.
    In a survey, they ranked ETI as their most important skill followed by defibrillation and patient assessment.
  • 81. Summary
    When paramedics were confronted with the many negative studies on ETI, they became ad hominem and said that the studies were a priori (especially Wang and Davis).
  • 82. Summary
    If ETI remains in a system:
    1. There must be adequate initial education including OR time.
    2. There must be a constant monitoring of skills performance.
    3. Paramedics not receiving enough ETIs annually must undergo refresher training.
    4. Probably should not intubate pediatrics of moderate to severe TBI patients.
  • 83. Summary
    If ETI remains in a system:
    5. Waveform capnography should be mandatory.
    6. All receiving hospitals should document tube placement.
    7. Alternative (rescue) airways must always be available.
    8. Failure to intubate is not a deficiency—failure to ventilate is.
  • 84. Summary
    The design and efficacy of alternate airways has reached a point where they can be used in EMS in lieu of ETI.
  • 85. Summary
    New technologies may improve paramedic ETI performance:
    GlideScope Ranger
    McGrath Video Laryngoscope
    Supraglottic Airway Laryngopharyngeal Tube (SALT)
  • 86. Summary
    Ironically, it is not the accumulating body of evidence that will be the death knell for prehospital ETI.
    It will be the lack of opportunity for OR exposure.
  • 87. Summary
    We must re-task our paramedics and change the educational approach:
    It is not the airway, it is ventilation that the patient needs.
    Airway is a technique or device to used to ventilate a patient.
    Failure to place an airway is not substandard care.
    Failure to ventilate a patient is substandard care.