ET vs laryngeal tube Pragmatic Airway Resuscitation Trial abstract

[Carlos Danger]

If you are successful as an agency at intubating, why would you get rid of ETTs. While this study shows better outcomes with the LTs, i dont think its because of the physical plastic tube. My takeaway from this is that people who have low exposure and opportunity to intubate stink at it, and that delay of a an airway is what causes the poorer outcomes.

I think it's quite clear that a big part of the reason that the research is so unsupportive of prehospital intubation is the fact that most paramedics just aren't very good at it because they don't do it very often. But there's more to it than that, as this study indicates.

As far as my agency goes, "Expected clinical course" is a big point of emphasis for our MD and the hospitals. They very much emphasis that if we think this patient is going to get intubated in the hospital, then knock them down in the field.

Even if one were to assume that prehospital intubation is beneficial as opposed to the alternatives (a claim which has never been proven despite many attempts), how could one possibly think that just because a patient might have a critical procedure performed in the hospital later on, that they are automatically better off having that critical procedure done in a setting with much less expertise and resources?

 

[rescue1]

I was just responding to your comment that you get more of your tubes from non-arrest patients--most of our tubes (no real RSI in Pennsylvania) are arrests.

Unfortunately this study doesn't address the effect of 1st time success with ETTs, so for now we have no idea what change that would have. To be honest, I'm suspicious any large study like this will ever show significant superiority--we all talk about how our first pass success rates are 80, 90% on the internet, but outside of physicians and helicopter EMS most ground medics in big urban departments have much lower success rates, in the 40-60% range. I did research with a big southern US fire department's cardiac arrest data and they had like a 45% first pass success. They've since switched to SGAs first line for arrests, but it was pretty eye opening. That's what prompted me saying that we'd have to take the tubes off the truck at my service if SGA became standard of care--if you lose 80% of your intubations there's no way you can stay competent.

I think in the future we'll see intubation move from a skill all paramedics have to a skill reserved for "advanced care" paramedics who have the opportunity to intubate more regularly and therefore be more proficient at it. Or in urban systems, where the hospital is less than ten minutes away, it may not make sense to have prehospital intubation at all.

 

[FiremanMike]

It wasn't in the presentation... but all the preoxygenation data I know is for people who are NOT in cardiac arrest.

I am not aware of any evidence for improved outcomes from preoxygenation DURING CARDIAC ARREST prior to ETI. Why would it? Hands off and you aren't circulating the oxygenated blood. Plus, preoxygenation is hard when you have to pause compressions to hyperventilate with the BVM... so then you are left with putting a HFNC under the BVM... or NRB and continuous compressions... I mean you could do some trials but I'm not seeing a strong rationale why this would change for ETI vs LT (you'd do it for both groups).

I speculate hands off time is probably the the biggest contributor to the differences in outcomes, and that wouldn't change with preoxygenation. This study found that repeat attempts lead to statistically more >10sec compression pauses with ETI vs any other airway management strategy. We saw that the ETI group saw 2 or more attempts in almost half the cases. We can surmise more compression interruptions.

Meanwhile, we do know that ETI early during IHCA also has worse outcomes vs delayed (despite probably having more practiced intubators) and that video lyngoscopy doesn't decrease hands-off-chest time.

So what if you "preoxygenate" as above and then try to intubate while doing compressions? You are moving tidal volume with compressions and eliminating your preoxygenation nitrogen washout... and compressions make intubation harder so lower initial success rates. I'm not aware of any trials involving intubation during compressions. Interesting, but you are posing a completely separate intervention to be trialed.

The folks in Rialto studied apneic oxygenation via high flow cannula in the minutes leading up to intubation in OHCA. I believe their algorithm has them stop BVM ventilation after moving the patient from the floor to the cot, and then resume once an airway is placed.

I’m impressed with their study, primarily because they include all cardiac arrest data and not just the mythical Utstein arrest. I’m also impressed with the above linked ETI study and will be discussing it with my medical director.

 

[FiremanMike]

I was just responding to your comment that you get more of your tubes from non-arrest patients--most of our tubes (no real RSI in Pennsylvania) are arrests.

Unfortunately this study doesn't address the effect of 1st time success with ETTs, so for now we have no idea what change that would have. To be honest, I'm suspicious any large study like this will ever show significant superiority--we all talk about how our first pass success rates are 80, 90% on the internet, but outside of physicians and helicopter EMS most ground medics in big urban departments have much lower success rates, in the 40-60% range. I did research with a big southern US fire department's cardiac arrest data and they had like a 45% first pass success. They've since switched to SGAs first line for arrests, but it was pretty eye opening. That's what prompted me saying that we'd have to take the tubes off the truck at my service if SGA became standard of care--if you lose 80% of your intubations there's no way you can stay competent.

I think in the future we'll see intubation move from a skill all paramedics have to a skill reserved for "advanced care" paramedics who have the opportunity to intubate more regularly and therefore be more proficient at it. Or in urban systems, where the hospital is less than ten minutes away, it may not make sense to have prehospital intubation at all.

I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm got a fair amount of exposure to medics who are “good” at intubating and those who aren’t. From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..

 

[Summit]

I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm got a fair amount of exposure to medics who are “good” at intubating and those who aren’t. From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..

Exactly. And if the counter is, "well if they'd JUST studied really practiced and competent intubators as a group, maybe it would have been different," such results would STILL support the idea of restricting and reducing who can do ETI.

There is no way to make most paramedics experienced and practiced intubators. There are around 70K MDA/CRNA/AAs in the US but over 200K paramedics.

 

[FiremanMike]

Exactly. And if the counter is, "well if they'd JUST studied really practiced and competent intubators as a group, maybe it would have been different," such results would STILL support the idea of restricting and reducing who can do ETI.

There is no way to make most paramedics experienced and practiced intubators. There are around 70K MDA/CRNA/AAs in the US but over 200K paramedics.

I do think it's POSSIBLE to make paramedics competent at intubation, even if they aren't getting them on actual runs. The problem is, it's not practical from a financial standpoint and would also require a larger off-duty time commitment than most medics would be willing to invest.

It also doesn't help that our training tools are terrible at best. Why these large simulations companies refuse to develop a realistic airway trainer is beyond me. Real airways don't move like that, ever.

 

[rescue1]

I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm got a fair amount of exposure to medics who are “good” at intubating and those who aren’t. From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..

Yeah the only factor that wasn't controlled for was first pass success. So of the 1,500 ETT patients, about 800 had the tube on the first try, but the abstract has no data if those patients did better than the 700 who needed a second attempt/rescue airway. Hopefully it'll be in the final full publication.

Either way, like Summit said, I don't think there's a universe where paramedics as a national group are super great an intubating because there are so many paramedics and only a certain amount of intubation to go around.

 

[FiremanMike]

Yeah the only factor that wasn't controlled for was first pass success. So of the 1,500 ETT patients, about 800 had the tube on the first try, but the abstract has no data if those patients did better than the 700 who needed a second attempt/rescue airway. Hopefully it'll be in the final full publication.

Either way, like Summit said, I don't think there's a universe where paramedics as a national group are super great an intubating because there are so many paramedics and only a certain amount of intubation to go around.

Personally, I'm OK with 'first pass' success rate being uncontrolled, as I think it means this data is a more accurate representation of real life conditions.

 

[rescue1]

Yeah I meant as like a secondary data point. We're never going to see 100% success with paramedic intubation, but it would be nice to see if perfectly placed ETT tubes were better/the same/still worse than SGAs, even if it was just out of curiosity.

 

[StCEMT]

Just throwing this out for fun.