Paediatric prehospital tracheal intubation: What makes different our practice across the Ocean?

Abstract

We were very interested in the recent paper by Dr Eich and colleagues reporting their practice of paediatric prehospital intubation in an European EMS staffed by trained emergency physicians.1Eich C. Rossler M. Nemeth M. Russo S.G. Heuer J.F. Timmermann A. Characteristics and outcome of pre-hospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians.Resuscitation. 2009; 80: 1371-1377Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar This article could be another stone in the garden of tenants of bag-mask ventilation as mandatory alternative to emergency tracheal intubation (ETI) in children. In the last few years, as underlined by Eich et al., the conclusion drawn from North American studies, where ETI was performed by paramedics with poor clinical paediatric skills and practice, was that ETI was not superior to bag-mask ventilation since it could result in severe complications without increasing, by itself, survival.2Gausche 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 (700) Google Scholar From this study, corroborated by Cooper et al.,3Cooper A. DiScala C. Foltin G. et al.Prehospital endotracheal intubation for severe head injury in children: a reappraisal.Semin Pediatr Surg. 2001; 10: 3-63Abstract Full Text PDF PubMed Scopus (87) Google Scholar the resulting recommendation was to favour bag-mask ventilation instead of tracheal intubation in the prehospital settings. In European systems, where physicians are directly involved in scene management, paediatric ETI is a standard practice, resulting in a low incidence of severe complications. The success rate reported in Eich's study (98.3%) is the same as the one we observed in children with traumatic brain injury experiencing tracheal intubation by physicians with similar qualification and experience.4Meyer P.G. Orliaguet G. Blanot S. et al.Complications of emergency tracheal intubation in severely head injured children.Pediatr Anaesth. 2000; 10: 253-260Crossref PubMed Scopus (38) Google Scholar In a more recent observational study comparing our practice before and after publication of National guidelines regarding tracheal intubation and rapid sequence induction (RSI) in children with severe TBI, we found in 296 children (2–15 years old) a success rate of 100% with immediate complications in only 8% of the cases.5Martinon C, Duracher C, Blanot S, et al. Emergency tracheal intubation of severely head injured children: changing daily practice after implementation of National guidelines. Pediatr Crit Care Med. 2010; in press.Google Scholar These studies demonstrate the ability of emergency physicians to perform efficiently ETI in children, with a low incidence of immediate adverse effects when RSI is carefully selected. We can expect that similar experiences from other European countries could be published in the next future. The expected benefit of prehospital tracheal intubation in critically ill children is the ability to provide adequate ventilation, avoiding both hypoxemia and hypercapnia during scene management and transport. This goal could be achieved by different means: reducing delay in definite hospital management in the “scoop and run” philosophy, or intubating rapidly, and successfully, those who need immediate airway assistance in the “stay and stabilize” philosophy. Finally, more than trying to demonstrate the superiority of one system compared to another, and to impose biased evidences as the truth, and nothing but the truth, a reasonable and consensual recommendation could be diffused worldwide. It could be that: the most effective system is the best adapted to regional medical organization and resources, major conditions for successful prehospital paediatric airway management programs are to focus resources on regular experience, and close monitoring of a limited group of trained providers,6Adelson P.D. Bratton S.L. Carney N.A. et al.Guidelines for the acute medical management of severe traumatic brain injury in children and adolescent. Chapter 3: Prehospital airway management.Pediatr Crit Care Med. 2003; 4: S9-S11PubMed Google Scholar and finally National recommendations for prehospital management should be adapted to the effective skills of EMS personnel involved in daily practice. None to declare.