I have being reflecting lately on intubation of critically ill patients. There are few other topics in prehospital care which raise strong opinions, often from polar perspectives. There are numerous papers on the safety and effectiveness of advanced airway management in multiple populations (http://wp.me/P2N7pf-2K) often with conflicting results.
Unfortunately, training in airway skills is very heterogeneous – with the majority of paramedics learning all airway skills in simulated settings and utilising these skills infrequently on real patients. All paramedics are expected to be proficient at bag mask ventilation, insertion of oropharyngeal airways (OPA), nasopharyngeal airways and supraglottic airways (SGA) however most have learnt these skills on manikins; will have infrequently used these skills in practice and typically use/attempt these skills without a more senior mentor being present. It is therefore difficult for paramedics to acquire / maintain “basic” airway skills of which the use of an OPA and ability to mask ventilate are the most important. Additionally, there is evidence that paramedics success rates for insertions of laryngeal mask airways is well below what is expected (i.e. > 90%). The majority of intensive care paramedics (ICPs) in Australia have undertaken some perioperative airway training however this is of variable duration (typically between 1-4 weeks) with some jurisdictions requiring a minimum of 20 intubations. ICPs are aware after this period of training that the perioperative area is very different to the prehospital environment when it comes to endotracheal intubation. Furthermore, the opportunity for the majority of paramedics to perform endotrachael intubation are infrequent.
I want to take the opportunity to explore why placing a plastic tube in the trachea during cardiac arrest might adversely affect outcomes and propose ways that these factors might be overcome
|Intubation can impair the delivery of effective and minimally interrupted chest compressions||
|Intubation can lead to hyperventilation of patients||
|Paramedics only intubate infrequently||
|Oesophageal intubation will not be recognised||
|Paramedics will become fixated on needing to definitively secure the airway||
All “intubators” (whether medical or paramedical) have a responsibility to not harm their patients. Whilst proceduralists like performing procedures, there is a patient at the end of every procedure. It is highly unlikely that the endotracheal tube reacts with the mucosa of the trachea in such a way that outcomes are worse – there must be other reasons. In my mind, all of which readily come to mind can be overcome quite readily.
- Intubation must not impair effective and continuous (or minimally interrupted) chest compressions
- Attempts at intubation must be brief, consider delaying until after ROSC
- Do not hyperventilate – use a ventilator if available (if unavailable lobby the bureaucracy)
- Optimise first pass success – optimise positioning, use external laryngeal manipulation, use suction and use a bougie
- Waveform capnography should be used routinely (if unavailable lobby the bureaucracy)
- If any difficulty – move on (don’t let your ego get the better of you – display clinical leadership by implementing plan B which facilitates oxygenation / ventilation