Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis

Alan A Garner,Andrew Weatherall,Nicholas Bennett,Anna Lee

doi:10.1186/s13054-020-02865-y

Alan A Garner, Andrew Weatherall + Show 2 more

Open Access

https://doi.org/10.1186/s13054-020-02865-y

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Abstract

BackgroundClinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team.MethodsWe searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions.ResultsForty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants.ConclusionPhysician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.

Highlights

Clinical team composition for prehospital paediatric intubation may affect success and complication rates
Success rates are reported to be lower in children and the complication rate higher [5, 6]
Ground emergency medical service (EMS) systems have intubated children without muscle relaxants, but many systems are introducing relaxants into their clinical protocols with the expectation that overall success rates would improve and that intubation could be offered for a wider range of pathologies

Summary

Introduction

Clinical team composition for prehospital paediatric intubation may affect success and complication rates. Airway management is a critical component of prehospital care for severely ill and injured children. As hypoxia correction is a time critical intervention, an emergency medical service (EMS) system must be able to provide airway management as early as possible, preferably at the incident scene. Intubation is generally considered to be the gold standard for airway management in the critically ill and injured. Children typically comprise only about 5% of total EMS cases [1,2,3], and those requiring intubation vary from 0.1% of all EMS responses [3, 4] to approximately 5% of paediatric cases when advanced intervention teams are selectively utilised [1, 2]. There are recent reports that physician staffed helicopter EMS (PS-HEMS) may produce high procedural success with low complication rates [7,8,9,10]

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