Transcript The Future of the Endotracheal Tube

The Disappearing
Endotracheal Tube
Bryan Bledsoe, DO, FACEP
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
INTRODUCTION
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.
Introduction
Eventually,
paramedics were
accepted into the
operating room for
clinical ETI education.
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.
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.
Introductions
Paramedics were now
intubations patients
who had a good
chance of survival.
This subsequently
put the practice in a
whole new light.
Introduction
Now that it mattered,
it was found that
paramedic ETI
success rates were
woefully low.
Introduction
Procedures were
changed and devices
were added to
improve the success
rate of prehospital
ETI.
Introduction
Scrutiny has now
moved to patient
outcomes.
IS ETI THE GOLD STANDARD?
Gold Standard?
Is the endotracheal
tube still the gold
standard for
prehospital care?
In certain situations,
maybe yes; in other
situations, maybe no.
Gold Standard?
“Endotracheal
intubation is the most
definitive means to
achieve complete
control of the
airway.”
Gold Standard?
“This [ETI] is the
preferred technique
for managing a
patient’s airway in the
field setting.”
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
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.
HAVE PARAMEDICS EVER
BEEN GOOD AT ETI?
Are Paramedics Good at ETI?
Paramedic education
courses have always
been rather brief
when compared to
other allied health
professions.
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.
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.
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
Are Paramedics Good at ETI?
Author(s)
No of Intubations
(Misplaced/Total)
Misplaced Intubations (%)
Jenkins et al
2/39
5.1
Bozeman et al
1/100
1
Stewart et al
3/779
0.4
Sayre et al
3/103
2.9
Pointer
5/383
1.3
•Jenkins, WA, Verdile VP, Paris PM. The syringe aspiration technique to verify endotracheal tube position. Am J Emerg
Med. 1994;12:413-416
•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.
•Stewart RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical personnel. Chest. 1984;85:341345.
•Sayre MR, Sackles JC, Mistler AF, et al. Field trial of endotracheal intubation by basic EMTs. Ann Emerg Med.
1998;31:228-233.
•Pointer JE. Clinical characteristics of paramedics’ performance of endotracheal intubation. J Emerg Med. 1988;6:505509.
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
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
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.
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
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
Are Paramedics Good at ETI?
1989 study of
pediatric cardiac
arrests:
Aijian P, Tsai A, Knopp R, Jailsen GW. Endotracheal
intubation of pediatric patients by paramedics, Ann Emerg
Med. 1989;18:489-94.
ETI success rate: 64%
63 pediatric patients
in Milwaukee County,
WI:
ETI success rate: 78%
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.
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
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.
Bellingham, WA:
Wayne MA, Friedland E. Prehospital use of succinylcholine: a 2020-year review
year review. Prehosp Emerg Care 1999;3:107-9.
95.5% ETI success rate
0.3% UEI
PREHOSPITAL INTUBATIONS
OUTCOMES
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?
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
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;58:9339.
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-valvemask ventilation. J Trauma. 2004;56:531-536
Outcomes
Pennsylvania Trauma
Registry:
4,098 trauma patients
43.9% received
prehospital ETI.
56.1% received inhospital 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.
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.
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. Prehosp Emerg Care. 2008;12:459-466
Outcomes
Mortality by Distance Category
Odds Ratio (95% CI)
Nonintubated patient at any distance
Reference
OOH-ETI with distance < 10 miles
2.70 (1.63-4.46)
OOH-ETI with distance 10 miles - <20 miles
1.87 (1.09-3.21)
OOH-ETI with distance 20 miles - <30 miles
1.80 (0.92-3.52)
OOH-ETI with distance 30 miles - <40 miles
0.90 (0.38-2.16)
OOH-ETI with distance 40 miles - <50 miles
0.20 (0.02-1.65)
OOH-ETI and  50 miles
1.83 (0.61-5.46)
Helicopter
0.36 (0.24-0.56)
Propensity
119.61 (65.63-217.99)
Outcomes
Australia:
“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 roadbased paramedics, rapid
transport to hospital
SA. Paramedic intubation of patients with severe head
without intubation should Bernard
injury: a review of current Australian practice and recommendations
for change. Emer Med Australas. 2006;18:221-8.
be regarded as the
standard of care.”
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.
Outcomes
Pediatric ETI:
No significant
difference in survival
to discharge or
neurological status at
discharge between
groups.
RCT of 830
consecutive children <
12 years of age (or
who were estimated to
weigh < 40 kg).
Randomized to
receive:
Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, et al.
Effect of out-of-hospital pediatric endotracheal intubation on
BVM ventilation
survival and neurological outcome: a controlled clinical trial.
JAMA. 2000;283:783-790
BVM ventilation
followed by prehospital
ETI.
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.
CHANGES IN GENERAL
ANESTHESIA PRACTICE
Anesthesia Practice Changes
Decreased ETI for
general anesthesia
due to acceptance of
the LMA and similar
supraglottic airways.
Anesthesia Practice Changes
HIGH
• Anesthesiology Residents
• CRNA Students
HIGH
• Critical Care/Emergency Residents
• IM/General Surgery Residents
MEDIUM
LOW
• Medical Students
• Respiratory Therapy Students
• Paramedic Students
• EMT-Intermediate Students
DECREASED OPERATING
ROOM EXPOSURE
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.”
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).
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
Decreased OR Exposure
Psychomotor skill development:
Imitation
Manipulation
Precision
Articulation
Naturalization
Students should reach this
point prior to graduation
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.
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
Increased Experience & Survival
Evaluation of
paramedics in
Pennsylvania 20002005:
Low (1-10 ETIs)
Medium (11-25 ETIs)
High (26-50 ETIs)
Very High (> 50 ETIs)
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%)
Survival:
Cardiac arrest: 17.4%
Non-arrest: 68.2%
Adjusted survival was
higher for cardiac
arrest patients
intubated by high- and
very-high-ETIexperience paramedics.
Increased Experience & Survival
Survival odds ratio
(compared to low ETI
experience) [95% CI]:
Medium: 1.04 (0.911.18).
High: 1.18 (1.01-1.38).
Very High: 1.29 (1.041.61).
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 (1.212.10).
Wang HE, Balasubramani KG, Lave JR, Yealey DM, Cook LJ.
Paramedic endotracheal intubation experience improves
survival. [Abstract] Prehosp Emerg Care. 2009;13:90-91.
DECREASED FIELD
OPPORTUNITIES
Decreased Field Opportunities
It has been generally
assume that ETI and
IV therapy were the
most frequently
performed paramedic
skill.
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.
Factors:
Number of patients
who require ETI not as
high as thought.
Number of providers
authorized to perform
ETI has increased
dramatically.
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.
Decreased Field Opportunities
Rural state (Maine)
study:
957,836 patients
encounters during 5year study period.
Average number of
EMS providers who
could perform ETI.
5,612 total ETI
attempts during the 5year 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.
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.
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
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.
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
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.
BETTER ALTERNATIVE
AIRWAYS
Better Alternative Airways
When EMS began,
there was really no
acceptable alternative
to ETI.
Better Alternative Airways
First-generation
airways:
EOA
EOA-GT
Problems:
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.
Better Alternative Airways
Second-generation
airways:
PtL
ETC
ETC first alternate
airway to receive
significant OR usage.
Better Alternative Airways
Third-generation
airways much better.
Primarily
supraglottic.
LMA
Cobra
Better Alternative Airways
CobraPLA
CobraPlus
King LT
LMA
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.
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
Chin L, Hsiao AL. Randomized trial of endotracheal tube versus
laryngeal mask airway in simulated pediatric cardiac arrest.
Pediatrics. 2008;122:e294-e297.
Malpositioning:
Esophageal = 9 (17%)
Right mainstem = 14 (27%)
LMA malposition = 5 (9.5%)
LITIGATION
Litigation
Alleged airway
misadventures are
still a major cause of
malpractice suits.
10-year review by one
malpractice carrier:
Cumulative claims
from these 10 cases >
19.6 million dollars.†
24 EMS claims
10 (42%) airwayrelated.
† - HPSO
SUMMARY
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.
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).
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.
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.
Summary
The design and
efficacy of alternate
airways has reached
a point where they
can be used in EMS
in lieu of ETI.
Summary
New technologies
may improve
paramedic ETI
performance:
AirTraq
GlideScope Ranger
McGrath Video
Laryngoscope
Supraglottic Airway
Laryngopharyngeal
Tube (SALT)
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.
Summary
We must re-task our paramedics and
change the educational approach:
1. It is not the airway, it is ventilation that the
patient needs.
2. Airway is a technique or device to used to
ventilate a patient.
3. Failure to place an airway is not
substandard care.
4. Failure to ventilate a patient is substandard
care.