Discussion Response 1
“Much debate has occurred recently about high failure rates and adverse effects associated with pre-hospital paramedic endotracheal intubation. Should ETT be removed entirely and replaced with supraglottic airways?”
Maintaining an airway in a safe and effective manner is critical in pre-hospital management of the patient in respiratory distress. The debate regarding the most appropriate device to manage this situation in the pre-hospital setting will continue as devices and education and training of paramedics continues to improve.
This discussion compares the failure rates and adverse effects of endotracheal intubation to supraglottic airway devices and discusses the possibility of removal of endotracheal tubes in favour of the use of supraglottic airways.
The indications for endotracheal intubation for Victorian Paramedics are cardiac arrest, respiratory arrest, GCS greater than or equal to 10 with suspected airway burns (a consult is required), GCS less than 10 due to respiratory failure, neurological injury, overdose, status epilepticus, hyperglycaemia with blood glucose level reading “high” or suspected airway burns. The paramedic requires clinical experience to recognise the 5 main indicators for intubation – failure to ventilate, failure to oxygenate, inability to protect against aspiration, inability to maintain airway patency or predicting patient deterioration to respiratory failure (Lafferty & Dillinger, 2016).
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Intubation success rates range from 69% to 98.4% the variation accounts for the level of education, training and case exposure. The success rate or lack thereof is directly proportional to the amount of education, training and case exposure received (Jacobs & Grabinsky, 2014 and Piegeler, et al., 2016). In Australian studies it was found that Victorian HEMS based paramedics who underwent extensive training that included hospital based practice (Bernard S. A., et al., 2015) attained 97% (Bernard S. , Smith, Foster, Hogan, & Patrick, 2002) – 100% (Andrew, et al., 2015) success rate. These intubations showed improvements with oxygen saturation, end tidal carbon dioxide levels, blood pressure (Bernard S. , Smith, Foster, Hogan, & Patrick, 2002) and pain scores (Andrew, et al., 2015). There is a recommendation from the European Resuscitation Council that only well trained and experienced paramedics should perform endotracheal intubation and alternate airway devices should be used by less trained paramedics (Schalk, et al., 2012). Failure to maintain competency of this skill increases the risk of errors eliminating the benefits of endotracheal intubation and results in a negative patient outcome (Tiah, et al., 2014).
Endotracheal intubation is performed to ensure adequate ventilation and oxygenation also to avoid aspiration of gastric contents or blood during cardiopulmonary resuscitation (Piegeler, et al., 2016) and when the airway is threatened due to oedema in the setting of facial burns or suspected inhalation burns (Price & Milner, 2012). Improved patient outcomes were demonstrated when endotracheal intubation was successfully achieved compared to those with a supraglottic device, there was a higher incidence of return of spontaneous circulation, survival to hospital admission, neurologically intact, survival to hospital discharge. (Benoit, Gerecht, Steuerwald, & McMullan, 2015).
Temporary harm from airway management is common however serious injury is not (Cook & MacDougall-Davis, 2012). Complications attributed to endotracheal intubation are commonly hoarseness and sore throat, however patients can also experience lip swelling, laceration and bleeding, tongue laceration and bleeding, oral bleeding, dental damage, gingival bleeding, and pharyngeal bleeding (Toda, Toda, & Arakawa, 2013). Failed intubation is associated with oxygen desaturation, hypertension, admission to ICU and complications at extubating (Cook & MacDougall-Davis, 2012). The risks associated with out of hospital endotracheal intubation are pulmonary aspiration, delay in transport due to several attempts, tube misplacement or “difficult airway management”. In these cases, where an invasive and time consuming technique may delay definitive care it may be more appropriate to utilise a supraglottic airway device as an alternative (Piegeler, et al., 2016).
The indications for the use of a supraglottic airway device are unconscious patient without gag reflex, ineffective ventilation with BVM and oro- or nasal-pharyngeal airway, predicted greater than 10 minutes assisted ventilation required, or unable to intubate or difficult intubation (Ambulance Victoria, 2016). Many studies indicate a less than 1% failure rate of supraglottic airway devices (Cook & MacDougall-Davis, 2012) this is due to the lower education and training requirement and the device being less invasive (Jacobs & Grabinsky, 2014). The failure rates were contributed to airway soiling and aspiration before paramedic treatment commenced. Proficiency of use is quickly attained (Haske, Schempf, Gaier, & Niederberger, 2013), the device is faster to insert with higher success rate (Duckett, Fell, Kimber, & Taylor, 2014) decreasing interruptions during a cardiac arrest and ventilation is possible with continuous compressions (Haske, Schempf, Gaier, & Niederberger, 2013).
The i-gel is a 2nd generation supraglottic airway device that exerts very low pressures on the pharyngeal mucosa resulting in low incidence of airway complication such as hoarseness and sore throat (Michalek, 2013). The major concerns of the use of any supraglottic airway device is the potential for air leak, airway, vocal cord and soft tissue injury, hypoxemia, and hypercapnia (Jacobs & Grabinsky, 2014) and aspiration of gastric contents (Piegeler, et al., 2016). This generation of device is designed with a channel to insert a gastric tube to drain the stomach contents or air (Michalek, 2013) to prevent aspiration.
Comparing placement success and time to ventilate when comparing unassisted endotracheal intubation and supraglottic airway device (Frascone, et al., 2011), hospital admission and survival to hospital discharge, and neurological or functional status (Tiah, et al., 2014) there is no significant difference between the two types of devices (Frascone, et al., 2011 and Tiah, et al., 2014).
In the metropolitan setting of paramedic practice there is a solid argument for the cessation of endotracheal use in favour of a supraglottic device. The low level of education and training required to ensure proficiency, fast insertion time and the addition of the gastric tube channel along with the shorter transport times to definitive care indicates that a supraglottic airway is most appropriate airway device.
Ambulance Victoria. (2016). Clinical Practice Guidelines for Ambulance and MICA Paramedics (Revised Edition ed.). Doncaster, Victoria, Australia: Ambulance Victoria. Retrieved March 19, 2017
Andrew, E., de Wit, A., Meadley, B., Cox, S., Bernard, S., & Smith, K. (2015, July/September). Characteristics of patients transported by a paramedic-staffed helicopter emergency medical service in Victoria, Australia. Prehospital Emergency Care, 19(3), 416 – 424. doi:10.3109/10903127.2014.995846
Benoit, J. L., Gerecht, R. B., Steuerwald, M. T., & McMullan, J. T. (2015). Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arret: A meta-analysis. Resuscitation, 93, 20 – 26. doi:10.1016/j.resuscitation.2015.05.007
Bernard, S. A., Smith, K., Porter, R., Jones, C., Gailey, A., Cresswell, B., . . . St Clair, T. (2015). Paramedic rapid sequence intubation in patients with non-traumatic coma. Emergency Medicine Journal, 32, 60 – 64. doi:10.1136/emermed-2013-202930
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Bernard, S., Smith, K., Foster, S., Hogan, P., & Patrick, I. (2002, December). The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury. Emergency Medicine Australasia, 14(4), 406 – 411. doi:10.1046/j.1442-2026.2002.00382
Bernhard, M., Mohr, S., A., W. M., Martin, E., & Walther, A. (2012, February). Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiologica Scandinavica, 56(2), 164 – 171. doi:10.1111/j.1399-6576.2011.02547
Cook, T. M., & MacDougall-Davis, S. R. (2012). Complications and failure of airway management. British Journal of Anaesthesia, 109(S1), i68 – i85. doi:10.1093/bja/aes393
Duckett, J., Fell, P., Kimber, C., & Taylor, C. (2014). Introduction of the i-gel supraglottic airway device for prehospital airway management in a UK ambulance service. Emergency Medicine Journal, 31, 505 – 507. doi:10.1136/emermed-2012-202126
Frascone, R. J., Russi, C., Lick, C., Conterato, M., Wewerka, S. S., Griffith, K. R., . . . Salzman, J. G. (2011). Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and supraglottic airway. Resuscitation, 82, 1529 – 1536. doi:10.1016/j.resuscitation.2011.07.009
Haske, D., Schempf, B., Gaier, G., & Niederberger, C. (2013). Performance of the i-gel during pre-hospital cardiopulmonary resiscitation. Resuscitation, 564, 72 – 77. doi:10.1016/j.resuscitation.2013.04.025
Jacobs, P., & Grabinsky, A. (2014, January – March). Advances in prehospital airway management. International Journal of Critical Illness and Injury Science, 4(1), 57 – 64. doi:10.4103/2229-5151.128014
Lafferty, K. A., & Dillinger, R. (2016, December 30). Rapid Sequence Intubation. (R. P. Byrd, Ed.) Retrieved March 19, 2017, from Medscape: http://emedicine.medscape.com/article/80222-overview#a1
Michalek, P. D. (2013). The I-Gel Supraglottic Airway. Nova Science Publishing Inc. Retrieved March 3, 2017, from http://ebookcentral.proquest.com/lib/vu/detail.action?docID=3022405
Piegeler, T., Roessler, B., Goliasch, G., Fischer, H., Schlaepfer, M., Lang, S., & Ruetzler, K. (2016, May). Evaluation of six different airway devices regarding regurgitation and pulmonary aspiration during cardiopulmonary resuscitation (CPR) – A human cadaver pilot study. Resuscitation, 102, 70 – 74. doi:10.1016/j.resuscitation.2016.02.17
Price, L. A., & Milner, S. M. (2012). The totality of burn care. Trauma, 15(1), 16 – 28. doi:10.1177/1460408612462311
Schalk, R., Auhuber, T., Haller, O., Latasch, L., Wetzel, S., Weber, C. F., . . . Byhahn, C. (2012, January). Implementation of the laryngeal tube for prehospital airway management: training of 1,069 emergency physicians and paramedics. Der Anaethesist, 61(1), 35 – 40. doi:10.1007
Tiah, L., Kajino, K., Alsakaf, O., Bautista, D. C., Ong, M., Lie, D., . . . Gan, H. N. (2014, November). Does Pre-hospital Endotracheal Intubation Improve Survival in Adults with Non-traumatic Out-of hospital Cardiac Arrest? A Systematic Review. Western Journal of Emergency Medicine, XV(7), 749 – 757. doi:10.5811/westjem.2014.9.20291
Toda, J., Toda, A. A., & Arakawa, J. (2013, October 17). Learning curve for paramedic endotracheal intubation and complications. International Journal of Emergency Medicine, 6(38). doi:10.1186/1865-1380-6-38
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