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We are pleased that the investigation has engaged national leaders in a discussion about out-of-hospital pediatric airway management. As detailed, the goal of this investigation was to describe the realities of process and outcome for out-of-hospital attempted pediatric intubation. We agree that each system must weigh the risks and benefits of different airway strategies in the context of the strengths and limitations of their emergency medical services providers. To achieve this understanding, we collect systematic information about each attempted intubation. The correspondents suggest a threshold of “above-average intubation” to justify paramedic pediatric intubation. The 66% first-pass success rate (75% with rapid sequence intubation) from the current experience compares favorably with published first-pass success in the pediatric emergency department (52% to 71%) and the pediatric ICU (62%).1Sagarin M.J. Chiang V. Sakles J.C. et al.Rapid sequence intubation for pediatric emergency airway management.Pediatr Emerg Care. 2002; 18: 417-423Crossref PubMed Scopus (156) Google Scholar, 2Kerrey B.T. Rinderknecht A.S. Geis G.L. et al.Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.Ann Emerg Med. 2012; 60: 251-259Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 3Nishisaki A. Turner D.A. Brown 3rd, C.A. et al.A national emergency airway registry for children: landscape of tracheal intubation in 15 PICUs.Crit Care Med. 2013; 41: 874-885Crossref PubMed Scopus (133) Google Scholar Thus, the informed approach would proceed with intubation in the out-of-hospital setting rather than delay definitive airway care for upwards of 30 minutes, given our system’s geospatial distribution. The correspondents cite the controlled trial that demonstrated a null survival result when comparing bag-valve-mask (BVM) ventilation to BVM ventilation plus intubation as evidence that pediatric intubation is not helpful.4Gausche M. Lewis R.J. Stratton S.J. et al.Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.JAMA. 2000; 283: 783-790Crossref PubMed Scopus (715) Google Scholar We agree this study provides useful information. However, the overall success rate for intubation was only 57%, a result that would not generalize to our current experience of 97% success. One could contend that intubation might be beneficial if the previous study had achieved proficiency of 97%. We agree that minimizing complications is important. Few out-of-hospital studies have reported the prevalence of such complications, so additional systematic assessment can determine whether these “complications” are simply markers of critical illness or a direct consequence of airway management. The current study did not measure ventilation. However, the correspondents imply that BVM provides relative protection against hyperventilation. Intubation and BVM strategies both have inherent hypo- and hyperventilation risk. BVM carries the added risk of gastric insufflation, emesis, and aspiration. King County incorporates intubation as part of a comprehensive pediatric airway strategy that includes BVM and supraglottic airways, as well as continuous oximetry and capnography. We retained the defibrillator recording for 27 of 50 pediatric arrest cases and confirmed endotracheal placement by continuous capnography in all 27. Finally, the correspondents suggest that 9% early extubation indicates safety risk. Alternatively, there are multiple circumstances in which transient intubation may be the physician standard. The concussed child with depressed consciousness and profuse vomiting or the seizing child who becomes apneic after receipt of appropriate antiepileptic medications both may be reasonable indications if the operator is capable. As the correspondents point out, our system design provides paramedics with substantial experience such that each paramedic performs an average of 15 intubations annually.5Prekker M.E. Kwok H. Shin J. et al.The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014; 42: 1372-1378Crossref PubMed Scopus (54) Google Scholar We acknowledge that King County can strive to improve airway management. And we remain committed to ongoing case-based and system-based review to guide our approach. We encourage the correspondents to help inform the topic by presenting their contemporary out-of-hospital pediatric (and adult) airway experience. It may well be that the King County approach is not appropriate in their systems. This type of comprehensive information will enable medical leaders to determine the strategy best suited for their system. Safety of Pediatric Out-of-Hospital Rapid Sequence Intubation Not DemonstratedAnnals of Emergency MedicineVol. 68Issue 1PreviewOur colleagues in King County recently reported on their experience with pediatric intubation (patients <13 years) by paramedics, including use of rapid sequence intubation.1 This is in stark contrast to practice patterns in our own regions, where pediatric intubation in general (or pediatric rapid sequence intubation in North Carolina) is not part of the current emergency medical services (EMS) scopes of practice. In accordance with the available literature, including a large, randomized, controlled, out-of-hospital trial,2 we believe the burden of proof for the EMS medical director should be to demonstrate above-average intubation performance and outcomes. Full-Text PDF