Out-of-Hospital Endotracheal Intubation May Worsen Outcome

Abstract

Source: Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA. 2000;283:783–790.Airway management is the first of the ABC’s of resuscitation. In the prehospital setting, endotracheal intubation (ETI) is becoming a popular adjunct to bag-valve-mask (BVM) ventilation to secure an unstable airway.1 However, ETI, especially for the pediatric patient, takes more time and requires more skill by prehospital personnel. To compare the survival and neurological outcomes of pediatric patients treated with BVM with those of patients treated with BVM followed by ETI, researchers conducted a 34-month controlled, clinical trial in Los Angeles and Orange counties—two large, urban, rapid-transport EMS systems. Unlike ETI in adult patients, ETI in children was not in the scope of practice for paramedics in these counties. Thus, the investigators trained 2584 paramedics in pediatric airway management, including the use of ETI, and received approval from all 115 paramedic receiving facilities in the study region. After completing training and skills testing for BVM and ETI, paramedics were allowed to enroll patients into the study.Eight hundred thirty consecutive patients aged ≤12 years (median age 1.2 years) or with an estimated weight of ≤40 kg who required airway management were enrolled. Patients were assigned to receive either BVM (odd days) or BVM followed by ETI (even days). When the data were analyzed by intention-to-treat (based solely on the date of enrollment and not the actual treatment received) there was no significant difference in survival between the BVM group and the BVM/ETI group (30% vs 26%, respectively) or in the rate of achieving good neurologic outcome (23% vs 20%). Secondary analysis based on paramedic intent (ie, what treatment the paramedic was intending to provide) similarly showed no significance between the BVM group and the BVM/ETI group (31% vs 26% for survival, respectively; 24% vs 20% for neurologic outcome). By treatment actually received, there were significant differences (P<.05) between the BVM group and the BVM/ETI group in both survival (33% vs 14%) and neurologic outcome (26% vs 8%). When the final outcome was determined for each patient, 3 of the 10 subgroups (respiratory arrest, child maltreatment, and foreign body aspiration) showed a significant worsening in survival or neurologic outcome with BVM/ETI relative to BVM. Time spent at the scene as well as total time from dispatch to hospital arrival was significantly longer for the BVM/ETI group.In the transport of critically ill or injured children, the classic dilemma is whether to “stay and play” or “scoop and swoop.” Although ETI is often the definitive technique for airway management, the practicality and efficacy of performing this procedure in the prehospital setting has not been well studied, primarily because of a variety of methodologic difficulties. This study is a tour de force that controlled for many potential flaws. In an attempt to standardize the providers’ skills, paramedics participated in a pediatric airway skills course. All paramedic receiving facilities were included so that consecutive patients could be enrolled. The manner in which the data were analyzed is also important. Although there is a tendency to divide patients into 2 groups based on the actual management they received, such grouping is misleading. For example, if a paramedic attempted to intubate a patient but was unsuccessful, it would introduce a bias to include that subject in a group of subjects who only had BVM. Furthermore, the success of ETI is not independent of prognosis; a child in cardiopulmonary arrest is often easier to intubate than a seizing child. Therefore, the investigators wisely analyzed the data according to the “intention-to-treat” principle. While it may seem intuitive that ETI at the scene would yield the best chance of survival, this study challenges this dogma. Although questions remain about paramedic training and the ability to generalize to all EMS systems, these results are intriguing.Because of the study design and size, these data seem compelling to us for most urban emergency medical service systems. With more rigorous and ongoing training it is possible that the results might have been different. The take-home message of this study is the same as is taught in PALS courses: the airway maneuver to master is BVM. Intubation is an important skill, but not as important as skillful BVM.