Endotracheal Intubation Attempts Research Articles

In reply: Is out-of-hospital intubation by paramedics valid enough to be continued?

To the Editor:As Dr. Morita and his colleagues describe in their Letterto the Editor, many recent studies have shown that out-of-hospital intubation is associated with decreased survival[1–3]. However, there are differences in the medicalbackground of the endotracheal intubation (ETI) performedin these studies and our study.The incidence of ETI attempted by paramedics in thereported studies was extremely high ([80%) in the USA[1–3], with ETI attempted in patients with a difficult air-way or with a Cormack grade of C2[2]. In the regioncovered by our study, ETI is not permitted as a routineprocedure for patients with out-of-hospital cardiac arrest(OHCA). In addition, ETI attempts are terminated whenthe Cormack grade of patient is C2.The etiology of cardiac arrest may have differedbetween the patients in our study and those of the otherstudies. In none of the three studies [1–3] did the patientsshow an etiology of cardiac arrest. Approximately 60–70%of cardiac arrest is related to coronary heart disease in theUSA [4]. In our study, we showed that implementation ofETI may worsen the outcomes in OHCA patients with acardiac etiology, but they may improve the outcomes inOHCA patients without a noncardiac etiology.Finally, ETI was repeatedly attempted by paramedics inthe USA [2]. In our region, only two attempts are made.The interruption of chest compression accompanying theETI was set at\30 s prior to November 2006 and at\10 sthereafter.The Ontario pre-hospital advanced life support(OPALS) respiratory distress study showed that the intro-duction of an EMS advanced-life-support program signif-icantly reduced the mortality of patients with shortness ofbreath [5]. Japanese paramedics are allowed to performETI immediately after they witness a cardiac arrest. Webelieve that effectiveness of ETI should be prospectivelyevaluated in OHCAs that occur following the arrival of theparamedic.In our study, we excluded 124 patients in whomadvanced airway management (AAM) was discontinued orfailed. Of these 124 patients, 52 were managed by non-certified paramedics and did not include cases of attemptedETI. In the remaining 72 patients, certified paramedicsattempted either ETI or another AAM procedure, or both.Therefore, the 124 patients varied widely in terms of AAMprocedure and were justifiably excluded from the analysis.The AAM procedure was more frequently attempted bycertified paramedics. However, we showed that manage-ment by paramedics qualified for ETI was not independentfactor associated with sustained return of spontaneouscirculation.More than 50 or 60 intubations may be necessary toachieve a 90% success rate when the ETI is attemptedwithout considering the Cormack. According to a pre-liminary analysis in our region, after paramedics have had15 consecutive cases with Cormack grade of 1, the successrate in the following ten cases exceeds 95%. The trainingprograms are considered to be appropriate for the patientswith a Cormack grade of 1.The harm caused by ETI should be minimized by edu-cation and continuous quality assurance. In our region, arecertification program for certified paramedics has been

Comparison of optical laryngoscope and the ordinary laryngoscope for emergency endotracheal intubation

Objective To evaluate the effectiveness and advantage of the TruviewTM EVO2(R) optical laryngoscope in comparison with the commonly used laryngoscope for the endotracheal intubation in patients in the emergency setting. Method Thirty-six patients in need for emergency endotracheal intubation in our hospital from February to May 2009 were randomly assigned to give intubation by using a TruviewTM EVO2(R) optical laryngoscope (T group) or a commonly used laryngoscope(R group). Cormack and Lehane laryngoscope grade (the degree of exposure of glottis by using laryngoscope), IDS (Intubation Difficulty Scale) score, the time taken for successful intubation, lowest SpO2 and the complication during intubation were essential factors for comparison between two groups. Results Our data showed that there was no difference in duration of the successful endotracheal intubation attempts between these two groups (respectively 22.73 ± 7.66 s and 19.91 ± 8.03 s, P ＞ 0. 05). However, the glottis exposure condition was significantly improved with TruviewTM EVO2(R) optical laryngoscope (P ＜ 0.01). The average IDS score for patients in T group was 0.33 ± 0.49, which is much lower than those in the R group (4.11± 0.90, P ＜ 0.01). In addition, the average SpO2 value measured in T group during the intubation operation was significantly higher than that in R group (98.87±0.74% and 91.45 ±4.86% respectively, P ＜0.01) and there was less complication observed in patients of T group. Conclusions Using TruviewTM EVO2(R) optical laryngoscope for emergency endotracheal intubation could help to expose the glottis in an ideal view, predominately lower the C/L grade and thus decrease the difficulty in intubation for clinicians. Its specially designed oxygen supplier allows the SpO2 to be maintained at a high level during the operation as well as reduce the incidence of complication. It is therefore extremely useful for emergency tracheal intubation, particularly a difficulty intubation situation. Key words: TruviewTM EVO2(R) laryngoscope; Emergency tracheal intubation; C/L grade; Glottis exposure; Complication

Rapid Sequence Intubation

Endotracheal intubation is often performed without the use of premedication and is therefore extremely distressing, painful and potentially damaging to the neonate. Pharmacological measures and effective pain relief for neonates undergoing invasive procedures have been shown to incur positive benefits on both the infant and health care provider.Rapid Sequence Intubation (RSI) is premedication prior to endotracheal intubation that includes analgesia, sedation, and a neuromuscular blockage. However, despite the evidence that it is safe and effective in neonates it is infrequently performed. RSI has been shown to reduce the number of endotracheal intubation attempts and decrease the amount of time needed for neonatal endotracheal intubation.

The Association Between Prehospital Endotracheal Intubation Attempts and Survival to Hospital Discharge Among Out‐of‐hospital Cardiac Arrest Patients

The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA. This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts. There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

Airway Management Success and Hypoxemia Rates in Air and Ground Critical Care Transport: a Prospective Multicenter Study

ABSTRACTObjective. To assess critical care transport (CCT) crews’ endotracheal intubation (ETI) attempts, success rates, and peri-ETI oxygenation. Methods. Participants were adult and pediatric patients undergoing attempted advanced airway management during the period from July 2007 to December 2008 by crews from 11 CCT programs varying in geography, crew configuration, and casemix; all crews had access to neuromuscular-blocking agents. Data collected included airway management variables defined per national consensus criteria. Descriptive analysis focused on ETI success rates (reported with exact binomial 95% confidence intervals [CIs]) and occurrence of new hypoxemia (oxygen saturation [SpO2] dropping below 90% during or after ETI); to assess categorical variables, Fisher's exact test, Pearson χ2, and logistic regression were employed to explore associations between predictor variables and ETI failure or new hypoxemia. For all tests, p < 0.05 defined significance. Results. There were 603 total attempts at airway management, with successful oral or nasal ETI in 582 cases, or 96.5% (95% CI 94.7–97.8%). In 182 cases (30.2%, 95% CI 26.5–34.0%), there were failed ETI attempts prior to CCT crew arrival; CCT crew ETI success on these patients (96.2%, 95% CI 92.2–98.4%) was just as high as in the patients in whom there was no pre-CCT ETI attempt (p = 0.81). New hypoxemia occurred in only six cases (1.6% of the 365 cases with ongoing SpO2 monitoring; 95% CI 0.6–3.5%); the only predictor of new hypoxemia was pre-ETI hypotension (p < 0.001). A requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (Fisher's exact p = 0.13). Conclusions. CCT crews’ ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO2 derangement. CCT crews’ ETI success rates were equally high in the subset of patients in whom ground emergency medical services (EMS) ETI failed prior to arrival of transport crews.

ProSeal laryngeal mask airway: An alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.

The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (P<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO2 (%) and EtCO2 levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.

Effect of Airway-Securing Method on Prehospital Endotracheal Tube Dislodgment

Objective. We compared the effectiveness of common airway-securing techniques in preventing endotracheal tube (ETT) dislodgment in the prehospital setting. Methods. This was a prospective, observational, multicenter study conducted at 42 emergency medical services (EMS) agencies. EMS providers completed structured, closed-response data forms for all endotracheal intubation (ETI) attempts during an 18-month period. We included all successful intubations as well as failed ETIs in which ETT securing was performed. EMS providers indicated methods used to secure the ETT, including the use of adhesive tape to the face (face tape), tape wrapped around the neck (neck tape), woven twill or umbilical tape (twill tape), intravenous or oxygen tubing (tubing), commercial tube holders, and manual stabilization/none. Providers also indicated the concurrent use of a cervical collar and/or cervical immobilization device (CID) with backboard. ETT dislodgment was reported by providers. We evaluated the rates and odds of ETT dislodgment for each tube-securing technique using multivariate logistic regression. Results. Of 1,732 patients undergoing tube-securing efforts, ETT dislodgment occurred in 51 (2.9%). ETT dislodgment rates were as follows: tube held manually, four of 32 (12.5%); face tape, 13 of 292 (4.5%); neck tape, nine of 205 (4.4%); twill tape, zero of 67 (0%); tubing, one of 30 (3.3%); commercial tube holders, 25 of 1,111 (2.3%); cervical collar, two of 121 (1.7%); and CID, 12 of 377 (3.2 %). On multivariate regression, when compared with securing the tube with face tape, only manually holding the tube in place showed a significant difference in the odds of dislodgment (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.2–15.2). Whereas cardiac arrest and trauma did not increase the odds of ETT dislodgment (OR 1.3, 95% CI 0.7–2.6; and OR 0.3, 95% CI 0.1–1.4, respectively), patient age less than 5 years was associated with ETT dislodgment (OR 6.6, 95% CI 2.2–19.7). Conclusion. In this multicenter observational series, the odds of ETT dislodgment were similar for face tape, neck tape, twill tape, plastic tubing, and commercial tube holders. ETT dislodgment did not occur with woven twill tape. Patients under 5 years of age are at heightened risk for ETT dislodgment.

Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service

Objective:To describe the safety profile of emergency airway management when performed by a prehospital team consisting of a doctor and a paramedic. Success rates, the incidence of difficult airways and...

Outcomes after out-of-hospital endotracheal intubation errors

We sought to evaluate the association between three key out-of-hospital endotracheal intubation (ETI) errors and patient outcomes. We prospectively collected multicenter data on out-of-hospital ETI attempted by Emergency Medical Service (EMS) rescuers. We probabilistically linked these data to statewide EMS, death and hospital discharge data sets. The key ETI error events were (1) endotracheal tube misplacement or dislodgement, (2) multiple ETI attempts (> or =4 laryngoscopies) and (3) failed ETI. The primary outcomes were death (survival to hospital discharge) and secondary complications identified through ICD-9 discharge diagnoses. Using Cox regression with heavyside functions, we identified the associations between out-of-hospital ETI errors and early (in the field or emergency department) and later (on or after hospital admission) death. We censored non-linked cases, adjusted for important clinical covariates, and used a shared frailty regression model to account for clustering by EMS agency. We evaluated the associations between out-of-hospital ETI errors and secondary complications using univariable odds ratios with exact 95% confidence intervals. Of 1954 out-of-hospital ETI, 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Of the 1196 (61%) cases linked to outcomes, 872 (73%) died and 323 (27%) survived to hospital discharge. ETI errors were not associated with early death (tube misplacement or dislodgement: Hazard Ratio 0.98, 95% CI 0.65-1.47; multiple ETI attempts: 1.22, 0.80-1.85; failed ETI: 1.10, 0.88-1.39) or later death (tube misplacement or dislodgement: 0.40, 0.10-1.62; multiple ETI attempts: 1.77, 0.23-13.30; failed ETI: 0.76, 0.47-1.25). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25). Out-of-hospital ETI errors are not associated with mortality. Failed out-of-hospital ETI increases the odds of pneumonitis.

The Impact of Rapid Sequence Intubation on Trauma Patient Mortality in Attempted Prehospital Intubation

Rapid sequence intubation (RSI) has been instituted in some prehospital settings to improve the success of endotracheal intubation (ETI); whether RSI improves outcomes is unclear. We sought to determine if trauma patients intubated with RSI in the prehospital setting had better survival compared to those intubated without RSI. Retrospective cohort analysis. We analyzed all injured adults (aged >or= 15 years) meeting state trauma system criteria, having a prehospital ETI attempt, and transported from the scene (19 counties) to one of the two state Level 1 trauma centers from 2000-2005. To adjust for the non-random selection of patients for field RSI, we built a propensity score from 15 important confounders, including demographics, injury severity, blood transfusion, surgical procedures, comorbidities, alcohol use, transport mode, injury mechanism, and initial field physiologic values. A propensity-adjusted multivariable logistic regression model (outcome = in-hospital mortality), with a time-based variable for system-wide implementation of changes in airway management, was used to test the association between RSI-ETI and mortality. There were 877 consecutive trauma patients who had prehospital ETI during this period and were included in the analysis. Of these, 496 (57%) had RSI-ETI. In univariate analyses, those with RSI-ETI had less severe injuries, better prehospital physiology (i.e., higher Glasgow Coma Scale score and blood pressure), fewer operations, fewer blood transfusions, and lower unadjusted mortality than those intubated without RSI. However, in the propensity-adjusted model, there was no statistical difference in mortality between the two groups (odds ratio 0.74, 95% confidence interval 0.52-1.06). Patients selected for RSI-ETI were less seriously injured, with better prognostic factors than intubated patients for whom RSI was not used. After adjusting for these differences, use of prehospital RSI-ETI was not associated with improved survival.

Patients with Difficult Intubation May Need Referral to Sleep Clinics

Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG). Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI >5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and chi(2) test. Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI >5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5-15), 6 (18%) had moderate OSA (AHI >15/h), and 6 (18%) had severe OSA (AHI >30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index. Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG.

King Airway Use by Air Medical Providers

Background. In cases of difficult or failed endotracheal intubation (ETI), alternate airways are designed to provide adequate oxygenation andventilation until a definitive airway can be established. The King Laryngeal Tube Disposable (LTD) is a new superglottic alternate airway. Objective. To describe the use, rates of success, andoutcomes of the King airway by highly skilled prehospital providers. Method. In this retrospective analysis, we examined prehospital King airway use by a large regional air medical service for the period from March 2006 to December 2006. Rescuers used alternate airways after three unsuccessful ETI attempts or in situations of anticipated ETI difficulty. We identified clinical characteristics, described airway difficulties, anddetermined the success of airway placement. Where available, we evaluated the hospital course andoutcomes. Results. Of 575 ETI, alternate airways were used in 27 cases, including 26 King airway placements (4.5%, 95% CI: 3.0–6.6%). All were successfully placed; 24 required one attempt, andtwo required more than one attempt. No immediate complications were observed. No prehospital surgical airways were performed. Follow-up data were available for 15 of 26 patients. Five patients were in cardiac arrest anddid not survive to hospital admission. Many of the patients required specialized efforts from anesthesia or surgery for definitive airway management with 40% (4/10) requiring emergent tracheostomy. Conclusion. In this series of critically ill patients, air medical providers successfully used the King airway as an alternate airway device. Definitive airway management was complicated andrequired specialized efforts from surgery andanesthesia.

How Many Attempts Are Required to Accomplish Out‐of‐hospital Endotracheal Intubation?

An important goal of emergency airway management is to complete endotracheal intubation (ETI) correctly, safely, and quickly, and repeated ETI attempts can increase patient morbidity and mortality. Clinical protocols limiting the number of ETI attempts may minimize harm, but this strategy also may reduce the frequency of successful ETI. To characterize the relationship between the number of out-of-hospital ETI attempts and ETI success. This study used prospective, multicenter data from 42 emergency medical services agencies from an 18-month period. Out-of-hospital rescuers (paramedics, out-of-hospital nurses, and physicians) completed structured, closed-response data forms describing clinical methods, course, and outcomes for all ETIs. An ETI attempt was defined as an insertion of the laryngoscope blade. Rescuers identified ETI outcome (success or failure) for each attempt. The authors defined overall success as ETI outcome (success or failure) on the last attempt, examining cardiac arrest, conventional nonarrest, sedation-facilitated, and rapid-sequence ETI separately. Univariate odds ratios (ORs) were used to identify the number of ETI attempts in which the cumulative ETI success rate approached the overall ETI success rate. Complete data were available for 1,941 cases. More than 30% of patients received more than one ETI attempt. For 1,272 cardiac arrest ETIs, cumulative success for the first three attempts were 69.9%, 84.9%, and 89.9%; cumulative success approached overall success (91.8%) after three attempts (OR, 0.79; 95% confidence interval [CI] = 0.61 to 1.04). For 463 conventional non-arrest ETIs, cumulative success for the first three attempts were 57.6%, 69.2%, and 72.7%; cumulative success approached overall success (73.7%) after two attempts (OR, 0.95; 95% CI = 0.71 to 1.28). For 126 sedation-facilitated ETIs, cumulative success for the first three attempts were 44.4%, 62.7%, and 75.4%; cumulative success approached overall success (77.0%) after three attempts (OR, 0.92; 95% CI = 0.51 to 1.64). For 80 rapid-sequence ETI, cumulative ETI success for the first three attempts were 56.3%, 81.3%, and 91.3%; cumulative success approached overall success (96.3%) after three attempts (OR, 0.41; 95% CI = 0.10 to 1.65). Out-of-hospital rescuers often require multiple attempts to accomplish ETI. A protocol limit of three attempts offers reasonable opportunity for accomplishing ETI within the constraints of the out-of-hospital environment.

Factors influencing emergency intubation in the pre-hospital setting—a multicentre study in the German Helicopter Emergency Medical Service

Definitive airway control by endotracheal intubation (ETI) is standard of care in pre-hospital airway management. However, there are specific factors that may influence and complicate ETI. Prospective, descriptive study at three German Helicopter Emergency Medical Services (HEMS) over a 1-yr period. We examined the success and complication rate for field intubation performed by trauma anaesthetists. In 342 patients (9.3%) ETI was performed. The overall success rate was 100%; in 87.4% the first attempt was successful, whereas in 11.1% a second and in 1.5% a third ETI attempt was necessary. No patient required a surgical intervention. Limited access to the patient was found upon arrival at the scene in 20.2% of the patients and in 9.6% of the patients at the time of ETI attempt. An orotracheal ETI technique was used in all patients. In the patients in whom only one ETI attempt was necessary for successful intubation, the assessment of ETI conditions was rated 'very good' or 'good' in 94.7%, but in those requiring a second or third ETI attempt this was reduced to 68.6 and 20.0%, respectively. Difficulties encountered during ETI included blood (19.9%), vomit/debris (15.8%) and secretions (13.8%) in the upper airway; anatomical reasons (11.7%), patient position (9.6%) and surrounding conditions (9.1%), making laryngoscopy more difficult. Despite various factors increasing the difficulties in managing the airway in the field, definitive airway control by ETI seems to be safe practice.

Drug-Assisted Effects on Protective Airway Reflexes During Out-of-Hospital Endotracheal Intubation (Preliminary Report)

Objective. Out-of-hospital rescuers often use drug-assisted intubation (DAI) to facilitate endotracheal intubation (ETI) of nonarrest patients. However, the relationship between the ablation of individual protective airway reflexes andresulting DAI success has not been defined. We sought to describe the relationship between the depression or ablation of protective airway reflexes andDAI success. Methods. We analyzed data from a prospective multicenter trial. Rescuers from 42 emergency medical services systems reported clinical ETI data using standardized reporting forms. We analyzed the subset receiving sedative and/or neuromuscular blocking agents to facilitate ETI. We defined successful ETI as intratracheal placement of the endotracheal tube on the last ETI attempt. Rescuers reported the presence andablation of six protective airway reflexes, including the presence of a gag, trismus, inadequate relaxation, combativeness, laryngospasm, andseizure/myoclonus. We examined the relationship between protective reflex ablation andDAI success. Results. Of 1,953 ETIs, 208 (10.7%) used DAI (128 sedation only, 80 neuromuscular blocking agents/rapid sequence intubation). Successful DAI was associated with ablation of gag reflex (odds ratio [OR], 12.7; 95% confidence interval [CI] 3.7 to 46.2), clenched jaw/trismus (OR, 54.4; 95% CI, 11.1 to 292.4), inadequate relaxation (OR, 16.3; 95% CI, 3.7 to 96.4), andcombativeness (OR, 10.2; 95% CI, 1.5 to 76.8). Successful DAI was associated with the total number of ablated protective reflexes (p < 0.001). Conclusions. The ablation of selected andthe total number of protective airway reflexes was associated with DAI success. Successful ablation of protective airway reflexes should be considered when attempting to characterize DAI performance or the effectiveness of specific drug facilitation regimens.

Endotracheal Intubation Attempts During Neonatal Resuscitation: Success Rates, Duration, and Adverse Effects

Endotracheal intubation of newborn infants is a mandatory competence for many pediatric trainees. The Neonatal Resuscitation Program recommends a 20-second limit for intubation attempts. Intubation attempts by junior doctors are frequently unsuccessful, and many infants are intubated between 20 and 30 seconds without apparent adverse effect. Little is known about the proficiency of more senior medical staff, the time taken to determine endotracheal tube (ETT) position, or the effects of attempted intubation on infants' heart rate (HR) and oxygen saturation (Spo2) in the delivery room (DR). The objectives of this study were to determine (1) the success rates and duration of intubation attempts during DR resuscitation, (2) whether experience is associated with greater success rates and shorter time taken to intubate, (3) the time taken to identify ETT position after intubation, and (4) the frequency with which infants deteriorated during intubation attempts and the time at which this occurred. We reviewed videos of DR resuscitations; identified whether intubation was attempted; and, when attempted, whether intubation was attempted by a resident, a fellow, or a consultant. We defined the duration of an intubation attempt as the time from the introduction of the laryngoscope blade to the mouth to its removal, regardless of whether an ETT was introduced. We determined the time from removal of the laryngoscope to the clinicians' decision as to whether the intubation was successful and noted the basis on which this decision was made (clinical assessment, flow signals, or exhaled carbon dioxide [ETCO2] detection). We determined success according to clinical signs in all cases and used flow signals that were obtained during ventilation via the ETT or ETCO2 when available. When neither was available, the chest radiograph on admission to the NICU was reviewed. For infants who were monitored with pulse oximetry, we determined their HR and Spo2 before the intubation attempt. We then determined whether either or both fell by > or =10% during the attempt and, if so, at what time it occurred. We reviewed 122 video recordings in which orotracheal intubation was attempted 60 times in 31 infants. We secondarily verified ETT position using flow signals, ETCO2, or chest radiographs after 94% of attempts in which an ETT was introduced. Thirty-seven (62%) attempts were successful. Success rates and mean (SD) time to intubate successfully by group were as follows: residents: 24%, 49 seconds (13 seconds); fellows: 78%, 32 seconds (13 seconds); and consultants: 86%, 25 seconds (17 seconds). Of the 23 unsuccessful attempts, 13 were abandoned without an attempt to pass an ETT and 10 were placed incorrectly. The time to determine ETT position in the DR was longer when clinical assessment alone was used. Infants who were monitored with oximetry deteriorated during nearly half of the intubation attempts. Deterioration seemed more likely when HR and Spo2 were low before the attempt. Intubation attempts often are unsuccessful, and successful attempts frequently take >30 seconds. Greater experience is associated with greater success rates and shorter duration of successful attempts. Flow signals and ETCO2 may be useful in determining ETT position more quickly than clinical assessment alone. Infants frequently deteriorate during intubation attempts. Improved monitoring of infants who are resuscitated in the DR is desirable.

The effect of Combitube use on paramedic experience in endotracheal intubation

Objective To determine the change in number of endotracheal intubations per paramedic after the implementation of Combitube use and to explore consequences. Methods Before-and-after study; urban/suburban EMS system; population 1 million. Number of patients 16 years and older, type of airway used, attempts, and successes were abstracted for time periods before and after the use of Combitubes. The number of endotracheal intubations/paramedic for each period was calculated. Results Three-year pre-Combitube: patients 50 983; 6.6% arrests; 3142 received an endotracheal intubation attempt with 93.5% success. The average annual number of paramedics was 153 with 6.9 ± 6.4 intubations per paramedic per year. Three-year post-Combitube: patients 55 959; 6.0% arrests; 2913 received an advanced airway attempt: 860 Combitubes, success 89.4%; 2144 endotracheal intubations, success 91.6% (95% confidence interval success rate difference, 0.5-3.3; P = .007). The average annual number of paramedics was 177 with 3.7 ± 3.3 intubations per paramedic per year. Conclusion After implementation of the Combitube, the number of endotracheal intubation attempts/paramedic and success rates decreased.

Airway Management by US and Canadian Emergency Medicine Residents: A Multicenter Analysis of More Than 6,000 Endotracheal Intubation Attempts

We determine success rates of endotracheal intubation performed in emergency departments (EDs) by North American emergency medicine residents. During 58 months, physicians performing intubations at 31 university-affiliated EDs in 3 nations completed a data form that was entered into the National Emergency Airway Registry 2 database. Included were all patients undergoing endotracheal intubation in the ED. The data form included patients' age, sex, weight, indication for intubation, technique of airway management, names and dosages of all medications used to facilitate intubation, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We queried this prospectively gathered, observational data to analyze intubations done by US and Canadian emergency medicine residents. Enrollment was incomplete (eg, 85% at the main study center), so the study sample did not include all consecutive patients. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the United States and Canada. The first intubator was successful in 90% (5,193/5,757; 95% CI 89% to 91%) of cases, including 83% (4,775/5,757; 95% CI 82% to 84%) on the first attempt. Success rates on the first attempt were as follows: postgraduate year 1 = 72% (498/692; 95% CI 68% to 75%), postgraduate year 2 = 82% (2,081/2,544; 95% CI 80% to 83%), postgraduate year 3 = 88% (1,963/2,238; 95% CI 86% to 89%), postgraduate year 4+ = 82% (233/283; 95% CI 77% to 87%), and attending physician = 89% (689/772; 95% CI 87% to 91%). Success rates by the first intubator were as follows: postgraduate year 1 = 80% (553/692; 95% CI 77% to 83%), postgraduate year 2 = 89% (2,272/2,544; 95% CI 88% to 90%), postgraduate year 3 = 94% (2,105/2,238; 95% CI 93% to 95%), postgraduate year 4+ = 93% (263/283; 95% CI 89% to 96%), and attending physician = 98% (755/772; 95% CI 96% to 99%). Rapid sequence intubation technique was used in 78% (4,513/5,768; 95% CI 77% to 79%) of initial attempts: it resulted in 85% (3,843/4,513; 95% CI 84% to 86%) success on the first attempt and 91% (4,117/4,513; 95% CI 90% to 92%) success by the first intubator. The overall rate of cricothyrotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). When an initial intubator failed, 40% (385/954; 95% CI 37% to 44%) of rescue attempts were performed by emergency medicine residents. Among emergency medicine residents, success on the first rescue attempt was 80% (297/371; 95% CI 76% to 84%), and success by the first rescue intubator was 88% (328/371; 95% CI 85% to 91%). Success of initial intubation attempts increased over the first 3 years of residency. This large multicenter study demonstrates the success of airway management by emergency medicine residents in North America. Using rapid-sequence intubation predominantly, emergency medicine residents achieved high levels of success.

Inverse intubation in air medical transport

Introduction The purpose of this study was to investigate the speed and accuracy of the inverse intubation procedure. Technique The operator crouches or kneels over the patient, straddling the torso. The laryngoscope is held in the operator's right hand in an overhand fashion, inserted gently into the patient's mouth, and pulled up and caudad. When the vocal cords are visualized, the endotracheal tube is passed with the left hand. Methods The procedure was taught to flight nurses and respiratory therapists ( n = 21) using an intubating mannequin strapped to a stretcher in a BK 117 helicopter to simulate an in-flight intubation. The subjects were timed intubating the mannequin using both inverse and standard intubation techniques. Each technique was performed twice, and the times were averaged. The Wilcoxon Signed Ranks test was used to determine statistical significance. Results No significant difference occurred between times of the standard (24.0 s) and inverse techniques (21.6 s) ( P = .715) or number of attempts for successful endotracheal intubation (1.12 and 1.07, P = .581). Conclusion Inverse intubation is a useful skill for prehospital providers. This skill can be taught in a brief period and used successfully with no compromise in speed or success rate.

Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation

Study Objective: Previous out-of-hospital airway management data are limited by small, single-site designs. We sought to evaluate the feasibility of performing a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation (ETI) using a standardized data collection tool. Methods: We designed a prospective multi-centered observational study involving 45 advanced life support (ALS) services from a mid-Atlantic state. Using a standardized data form, prehospital personnel reported details of each attempted ETI, including patient demographics, methods used, difficulties encountered, and initial patient outcomes. We calculated and assessed data form return rates (using independent queries of the number of ETI attempted by each EMS service) and missing data entry rates. We also performed preliminary cross-sectional assessments of factors of current interest in out-of-hospital ETI. Accuracy and validity of responses were not evaluated. Data were stored centrally and analyzed using descriptive techniques. Results: Participants included 8 urban, 15 suburban, 20 rural, and 2 air medical services. Data forms were received on 783 adults receiving ETI attempts during the study period June 1, 2001–November 30, 2001. The pooled data form return rate was 72.7%. Per-service return rates ranged from 0 to 100% and the median per-service return rate was 75%. Non-response (data form not returned for attempted intubation) was problematic, with nine services demonstrating data return rates less than 50%. Data return rates could not be calculated for an additional nine services. The missing data entry rate was 0.5–22.2%. The overall reported ETI success rate was 86.8% (92.8% for cardiac arrests and 76.8% for non-arrests) and did not appear to vary between population settings. There were two cases of delayed recognition of esophageal intubation, one case of unrecognized esophageal intubation, and 22 cases of tube dislodgement during patient care or transport. Bag-valve-mask ventilation was used as the rescue airway technique in the majority of failed ETI. When stratified for cardiac arrests vs. non-arrests, ETI success was not associated with field or initial ED survival. Conclusions: We successfully obtained complete data for the majority of ETI attempted across multiple EMS services. Our data also indicate the need to address problems with non-response. Preliminary cross-sectional data highlight areas of current interest in out-of-hospital airway management.