Abstract

To the Editor:As Dr. Morita and his colleagues describe in their Letterto the Editor, many recent studies have shown that out-of-hospital intubation is associated with decreased survival[1–3]. However, there are differences in the medicalbackground of the endotracheal intubation (ETI) performedin these studies and our study.The incidence of ETI attempted by paramedics in thereported studies was extremely high ([80%) in the USA[1–3], with ETI attempted in patients with a difficult air-way or with a Cormack grade of C2[2]. In the regioncovered by our study, ETI is not permitted as a routineprocedure for patients with out-of-hospital cardiac arrest(OHCA). In addition, ETI attempts are terminated whenthe Cormack grade of patient is C2.The etiology of cardiac arrest may have differedbetween the patients in our study and those of the otherstudies. In none of the three studies [1–3] did the patientsshow an etiology of cardiac arrest. Approximately 60–70%of cardiac arrest is related to coronary heart disease in theUSA [4]. In our study, we showed that implementation ofETI may worsen the outcomes in OHCA patients with acardiac etiology, but they may improve the outcomes inOHCA patients without a noncardiac etiology.Finally, ETI was repeatedly attempted by paramedics inthe USA [2]. In our region, only two attempts are made.The interruption of chest compression accompanying theETI was set at\30 s prior to November 2006 and at\10 sthereafter.The Ontario pre-hospital advanced life support(OPALS) respiratory distress study showed that the intro-duction of an EMS advanced-life-support program signif-icantly reduced the mortality of patients with shortness ofbreath [5]. Japanese paramedics are allowed to performETI immediately after they witness a cardiac arrest. Webelieve that effectiveness of ETI should be prospectivelyevaluated in OHCAs that occur following the arrival of theparamedic.In our study, we excluded 124 patients in whomadvanced airway management (AAM) was discontinued orfailed. Of these 124 patients, 52 were managed by non-certified paramedics and did not include cases of attemptedETI. In the remaining 72 patients, certified paramedicsattempted either ETI or another AAM procedure, or both.Therefore, the 124 patients varied widely in terms of AAMprocedure and were justifiably excluded from the analysis.The AAM procedure was more frequently attempted bycertified paramedics. However, we showed that manage-ment by paramedics qualified for ETI was not independentfactor associated with sustained return of spontaneouscirculation.More than 50 or 60 intubations may be necessary toachieve a 90% success rate when the ETI is attemptedwithout considering the Cormack. According to a pre-liminary analysis in our region, after paramedics have had15 consecutive cases with Cormack grade of 1, the successrate in the following ten cases exceeds 95%. The trainingprograms are considered to be appropriate for the patientswith a Cormack grade of 1.The harm caused by ETI should be minimized by edu-cation and continuous quality assurance. In our region, arecertification program for certified paramedics has been

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