the future of the endotracheal tube

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The Disappearing Endotracheal Tube Bryan Bledsoe, DO, FACEP Clinical Professor of Emergency Medicine University of Nevada School of Medicine

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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 patients 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 patients 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 carenot 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? 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;85:341- 345. 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;6:505- 509. 23. 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 24. 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 25. 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. 26. 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, OConnor RE, Rubinstein H. Failed prehospital intubations: an analysis of emergency department courses and outcomes. Prehosp Emerg Care. 2001;5:134-41 27. 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 28. 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% 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. Aijian P, Tsai A, Knopp R, Jailsen GW. Endotracheal intubation of pediatric patients by paramedics, Ann Emerg Med. 1989;18:489-94. 29. 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. 30. PREHOSPITAL INTUBATIONS OUTCOMES 31. 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? 32. 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 33. 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. 34. 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 35. 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. 36. 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. 37. 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 38. 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 -