Number Of Endotracheal Intubation Research Articles

Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review.

Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system. This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated. A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt. Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

Longitudinal and Regional Trends in Paramedic Student Exposure to Advanced Airway Placement: 2001–2011

Objectives. The primary aims of this study were to determine whether the frequency of placement, type of advanced airway, and settings of advanced airway placement (clinical vs. field) have changed for paramedic students over the last 11 years, and to describe regional differences regarding the same set of variables. Methods. This study was a retrospective review of prospectively reported airway procedures documented by paramedic students in Fisdap (http://www.fisdap.net). Students were included if they graduated from a paramedic program, had procedure entries verified by a preceptor, and provided consent for research. Exclusion criteria included students who had a total number of airway placements ≥2 standard deviations from the mean or had 0 airway placements recorded, and programs with <10 graduating students total over the study period. Airway device types and educational settings were descriptively compared over the 11-year study period by year and region. Results. A total of 8,934 paramedic student records were reviewed, with 2,811 excluded based on a priori criteria, leaving 6,123 records for analysis. In each year, the median number of airway devices placed per student was greater in the clinical setting. Endotracheal intubation (ETI) was more common than alternative airway placement in both the field and clinical settings. The median number of clinical ETIs per student has remained relatively constant at 7. The median number of field ETIs per student ranged from 0 to 1 over the study period, with a median alternative airway placement rate of 0 for both clinical and field settings. For all regions, the majority of procedures were performed in a clinical environment. The median number of clinical alternative airway device placements was 0 for all regions. The number of clinical ETIs ranged from 5 to 11 per student, with the highest number of ETIs per student in the West North Central and New England regions and the lowest in the West South Central and East South Central regions. Conclusion. Paramedic students gain the majority of their advanced airway experience in the clinical setting. ETI remains more common than alternative airway placement, although there is significant geographic variation in the number of ETIs per student. High rates of clinical intubations do not correlate with high rates of field intubations.

Complications of Endotracheal Intubation in Intensive Care Unit

Aim: We aimed to compare patients who developed complications during endotracheal intubation and who did not develop any complication in the Medical Intensive Care Unit. Material and Methods: We enrolled 39 patients into the study. Patients intubated outside the intensive care unit (emergency service, prior to operation) were excluded. All intubation procedures were performed by residents in internal medicine. Data about the patient and complications were recorded by the same person. Results: At least one complication was seen in 41% of all patients. Life-threatening complications such as severe hypoxemia (12%) and severe cardiovascular collapse (7%) were found. Difficult intubation (23%), aspiration (10%), esophageal intubation (10%), dental injury (10%), and dangerous agitation (3%) were found as moderate complications. Acute respiratory failure was the most common reason for intensive care unit admission (59%) and intubation (74%). Within one hour before intubation, the highest and lowest mean heart rate was higher than those who developed complications. No complications were observed in patients who were intubed at the first attempt. All complications occurred in patients who had two or more trials. Conclusion: Complications of endotracheal intubation is an important problem in intensive care units. Intubation success on the first attempt prevents complications. As the number of endotracheal intubation with the assistance of laryngoscopy increased, it was seen that complications related to the procedure also increased. (Yogun Bakim Derg 2011; 2: 39-43)

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...

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.

Defining the Learning Curve for Paramedic Student Endotracheal Intubation

Background. Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited. Objective. To evaluate the effects of cumulative live ETI experience, elapsed duration of training, andclinical setting on PS ETI proficiency. Methods. The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), andother hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success andthe PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, andthe interaction (cumulative ETIs × elapsed days). Predicted probability plots were constructed depicting the “learning curve” overall andfor each clinical setting. Results. Between one and74 ETIs (median 7; IQR 4–12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044–1.091). ETI learning curves were steepest for the ICU andprehospital settings but lower than for other clinical settings. Conclusions. Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical settings. Strategies for PS airway education must consider the volume of live ETIs as well as the clinical settings used for ETI training. Key words: intubation; intratracheal; emergency medical services; learning; allied health personnel.

Gender and Status Asthmaticus

Background. Adult women may be more susceptible to asthma than men. Hypothesis. Women are more likely to develop status asthmaticus (SA) requiring critical care. Methods. The medical records of patients admitted to our medical intensive care unit (ICU) for SA between 1994 and 2000 were examined. A number of demographic and physiologic variables were extracted from the medical records. Results. Of 103 total admissions, 53 (of 37 patients) were age <50 years and had clinical evidence suggesting SA. Among these 37 patients, the average (±SE) age was 30.8 ± 1.0 y with average acute physiology and chronic health evaluation (APACHE) II of 9.5 ± 0.8. Seventeen patients were Hispanic, 13 were black, and 7 were white. Twenty-four patients (accounting for 37 admissions) were female and 13 patients (16 admissions) were male. Although women accounted for a greater absolute number of endotracheal intubations (ETI; 17 vs. 12) and were more likely to be admitted to ICU more than once (7 vs. 3), men had a higher incidence of ETI (RR = 1.6; 95%CI = 1.04–2.6). The need for using therapeutic permissive hypercapnia and lengths of stay (ventilator, ICU, and hospital) were similar between men and women. Two patients, both women, died of causes not related to treatment of SA. Conclusions. These data suggest that although women accounted for more ICU admissions for SA, men were more likely to require ETI.

Hyaline Membrane Disease Treated With Early Nasal End-Expiratory Pressure: One Year's Experience

This report describes one year's experience treating hyaline membrane disease (HMD) with nasal end-expiratory pressure (NEEP). During the 12 months from July 1, 1973 through June 30, 1974, 119 children with HMD were admitted to the Intensive Care Unit of St. Paul Children's Hospital. Sixty-nine infants were treated early in the course of their disease with NEEP. The survival, incidence of complications, and the number of endotracheal intubations are reported and compared to our experience during a similar time period prior to the use of NEEP (1971-1972). Since the advent of the early application of modest amounts of end-expiratory pressure by nasopharyngeal tube, there has been an increase in the survival of all admissions with HMD, but the increase was statistically significant (P less than .01) only in those weighing 1,501 to 2,000 gm. There was a significant decrease (P less than .025) in the total number of children with HMD requiring endotracheal intubation. There was no change in the incidence of pneumothoraces or bronchopulmonary dysplasia. NEEP is a simple and effective technique for creating continuous airway distending pressure. Its effectiveness and ready availability make the routine endotracheal intubation of infants requiring only continuous airway distending pressure no longer justifiable.

Management of severe tracheal stenosis caused by repeated endotracheal intubation in a patient of myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction. The disease is characterized by exacerbation and remission of the symptoms from time to time. Myasthenic crisis is a serious complication of MG and is defined as weakness from acquired MG that is severe enough to require intubations [1]. Myasthenic crisis may complicate in 15-20% of patient with MG [2], [3]. Most patients require ventilation for a brief period, usually less than two weeks [4]. Repeated intubations may cause tracheal stenosis. The potential risk factors for post-intubation subglottic stenosis include, the underlying disease requiring endotracheal intubations(EI), the age and body weight, the duration and number of EIs, absence of sedation and the occurance of infections, hypotensive or hypoxic events during the period of EI and traumatic EI [5], [6].Key words: Tracheal stenosis, Repeated intubations, Myasthenia gravis.DOI: 10.3329/pulse.v3i1.6550Pulse Vol.3(1) July 2009 p25-26