Abstract
BackgroundPre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates.MethodsA systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis.ResultsOf the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616–1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938–0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616–1.000) and, for physicians, were 0.988 (0.781–1.000) (p = 0.003).DiscussionThe reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.
Highlights
Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are required
Of the 38 studies included, 19 (50%) were studies of non-physician-led services and 19 (50%) were studies of services staffed by physicians
The estimated overall intubation success rate of 0.969 (0.616–1.000) in the present meta-analysis is a significant improvement when compared to 0.927 (0.882–0.961) reported by Lossius et al [6] and 0.892 (0.877–0.905) reported by Hubble et al [7]. This improvement was observed in intubation success rates for non-physicians which increased from a median of 0.849 (0.491–0.990) [6] and 0.863 (0.826–0.894) [7] to 0.917 (0.616–1.000)
Summary
Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are required. There is a small but identifiable group of severely ill or injured patients in whom basic airway interventions do not provide adequate oxygenation and ventilation prior to hospital arrival [1]. To address these problems, prehospital advanced airway interventions, with or without the use of drugs, are frequently carried out. Given the complexity of pre-hospital advanced airway management, it is essential that all factors influencing intubation success are optimised prior to any intubation attempt. Monitoring the success rate of intubation is a factor describing the ability of a system to deliver high-quality airway management
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