The Great Airway Debate...

[VentMonkey]

Alright all, this is officially my first thread so go easy on me if you will.

This on going "hot button" issue has come and gone many times on this site, I am sure, but instead of revamping a necrothread I felt the need to create a new one. First, I will ask some of the questions that have come to mind recently, then I will share my thoughts, and comments. I look forward to everyone's input as well, so here goes nothing...

Do you feel advanced airway management (ETI) should disappear altogether in the prehospital setting? why or why not?

I don't think it should altogether, but that being said our level of training, and con-ed is severely lacking. I think advanced airway management should be reserved for certain patient populations only to include rural areas that permit RSI (e.g., ground services that have this capability). I also think that in general when I think advanced, only practioners that have, or seek this advanced training should be permitted, and if intubation is that important to you, then you will take the time to learn more about the importance of this procedure which includes anything from proper BLS techniques, when not to intubate, proper positioning, the RSI drug formulary, and what it is these drugs can, and cannot do. I also feel this is where the importance of vent management comes into play in the prehospital arena. Understanding that hand-bagging a patient for an extended period time is just BAD for these patients.

When it comes to who should be intubating, it's my belief that it should remain in the general paramedic scope to be taught, but there should be an exception to the rule that allows for us to utilize blind airway devices to secure their airway in the event that the patient is no more than, say, 10-15 minutes from the closest hospital if this is a straightforward arrest patient, and not one needing to be induced. Obviously, these devices are still excellent back up airways as well.

Is CPAP/ BiPAP something that should be implemented in ALL BLS providers scope of practice? Why or why not?

Absolutely. This is a fairly safe, easy, but more importantly effective skill to perform on certain patient populations that with proper training, I don't see or have a problem with my tech setting this up, in fact I often showed them how if they were interested. This goes for breathing treatment IMO as well (disclaimer: I am from California so this isn't really accepted here). The turn around on these patient such as flash pulmonary edema, is to me, as remarkable as say Narcan, and Dextrose reversals; not always, but usually.

Is the ventilator something that is being put into use in your service (I am more interested in ground 911 here, but all comers are welcome), and if so how much lee way do you have in terms of being able to make adjustments, or are you using basic setups such as the autovent? Do you feel that the ventilator is something that is ready to be added to the paramedic curriculum?

We don't do routine ground RSI here, however, my division does perform them, and has a specific ventilator protocol which includes parameters for certain patient populations. We don't use the autovent (thank goodness) anymore, and are actually in the market for an updated ventilator.

I do think that basic ventilator management should be taught in the national paramedic curriculum if we are to continue providing advanced airway management. Then again, so should the RSI formulary, which I know can get combed over depending on the paramedic school you go to. I don't think what would be taught needs to be anything more than ABG basics, ventilator terminology, settings, and parameters. I do think it's important for all paramedics to understand that at the very least the tool comes with the (or at least should) "airway package". Don't get me wrong, by no means am I discounting the importance of proper BLS airway manuevers, but I don't feel we as medics should be so apprehensive with the vent.

Finally, do you place gastric tubes on all patients that you intubate? Do you feel that it's imperative/ takes away from the "gold standard" that is often seen with ETI?

I don't/ haven't, but am beginning to understand the importance that it serves, specifically in the patient who has been RSI-d. When we do perform RSI we are to place them in as well, as well as on the vent. I understand time constraints, but it really does defeat the purpose of calling it a "gold standard" of an airway without a gastric tube in place, and has forced me to make a conscious effort to place them on any, and every patient RSI-d, or who are intubated, and to be transported.

This is the general gist of how I feel. I assure you this is NOT a homework assignment, I'm just genuinely curious as to what side of the fence my fellow EMS-ers stand on this on going discussion. Like I said, all input is really appreciated as I know there are some people on this forum we could benefit to learn from so hopefuly y'all feel compelled to join this discussion.

 

[SeeNoMore]

1.I think there is clearly a role for advanced airway management in the pre-hospital setting. I agree that advanced airway management should be performed by clinicians with a significant amount of education and exposure , and outcomes should be closely monitored. I think it is reasonable for Flight / Critical Care teams and Paramedics in rural areas w/ extended transport times to utilize RSI if they prove capable of a very high first pass success rate and appropriate pt management generally. I think it would be very reasonable to remove intubation from the general paramedic scope of practice.

2. CPAP for all providers? Yes certainly.


3. We do not use a vent at my ground per diem job though we RSI. This is an issue that has been discussed at length internally and there has been a push to purchase vents. I am a little unsure of adding vent management to the paramedic curriculum. I fear that spinning a few dials will be regarded as "understanding the vent". Then again, perhaps using some preset AC settings would be preferable to the general practice of aggressively hyperventilating patients. As per question 1 , I think it would be great for the teams that use RSI to have a vent. At least better than the autovent.

4. We typically do place gastric tubes on all pt's we RSI.

 

[SpecialK]

I think there is a role for both standard intubation (without medicines) and RSI in pre-hospital care. Having said that, the only indication I can logically see for standard intubation is GCS 3 and ineffective breathing (which is also the only indication in the CPGs) although, even then if an LMA was in place and working well, and hospital was reasonably close, I wouldn't do it.

Some ambulance services have removed endotracheal intubation on the basis it worsens outcomes as demonstrated in less than ideal quality studies. This is true, there is significant risk associated with "badly" attempting to intubate somebody; for example long periods of laryngoscopy, multiple attempts, attempting it on somebody who has a GCS of greater than three without RSI. All of the studies I am aware of have come from the United States, where large numbers of paramedics are able to intubate after, generally speaking, quite limited education, and may only intubate a very small number of people a year if that.

In Australasia; intubation is limited to Intensive Care Paramedics who have many years of education and experience; the standard for a number of years now has been a Postgraduate certificate or diploma on-top of the standard university degree to reach this level. The number of ICPs is also limited on the rationale of increasing the exposure these officers have to use their specific skills. On-top of this, those ambulance services (such as St John, WFA, the QAS, and AV) who are doing RSI also further limit to a group of selected ICPs. In Australia and Auckland, it is standard for HEMS to be crewed by a Doctor/Paramedic.

I strongly believe RSI should not only be in the "rural" area; I have seen many patients in an urban area who've had falls from height, road crash, post-cardiac arrest or stroke, poisoning etc benefit from RSI. You can be an hour from hospital, or two minutes, but if you have somebody with a severe traumatic brain injury for example who is all aggressive and fighty well doesn't really matter how close you are does it?

CPAP should absolutely be available; this seems to be standard in Australia.

 

[VentMonkey]

Awesome input so far. It's nice to see and know what others are doing, and why they're doing what they do.

I hope to hear from others as well (any and all providers be it EMT, interns, medics, RN's, docs, CRNA's etc.)

I hope everyone has a safe and enjoyable Labor Day.

 

[Carlos Danger]

My opinions on this issue are pretty much in line with the other posts so far in this thread.

There absolutely is a role for advanced airway management in the field, but I think it is pretty limited. The fact is, few patients really need intubation in the field, and those who do appear (according to what we are taught) to need it and receive it are statistically more likely to have a poor outcome. So we just aren't helping them, in most cases.

Most of this research was done in urban areas, however, and I think that if you have long transport times (rural areas) and/or transport an unusual proportion of high acuity patients (HEMS, for instance), then the chances of encountering patients who do really need it are higher. So in those settings I think it is appropriate. The other advantage of limiting who does RSI is that the limited resources for ongoing training can be focused on a smaller group of paramedics.

CPAP? Sure. Great tool.

OG tubes? Not routinely. Some of the worst messes I've seen followed OGT placement. If someone has an elevated intragastric pressure, then disruption of the esophageal sphincter with the GT makes emesis more likely. And they can puke much faster than you can suction. And if they don't have an elevated gastric pressure - and especially if you already have the airway secured with an ETT - then you don't need to decompress their gut. I don't place them routinely in the field or the OR. Only if indicated for other reasons.

 

[VentMonkey]

Thread bump...

So our program recently implemented ventilator placement for any, and all scene calls that are intubated. So far it seems to be going well. It frees up hands to perform other interventions. Obviously, it's much better for a patient than (inaccurately) squeezing air into their lungs, often incorrectly.

For any of the CCT/ HEMS people, with your service are you (paramedics) being trained on ventilator management as part of your initial new-hire training? Is it simply just learning how to dial in settings, or are you learning the ins and outs of vent management in the prehospital setting (ABG's, proper settings for different patient populations, formulas such as "Winter's Formula", etc.)? Do you feel it's that important, and if so, why or why not? Are the nurses at your service expected to be up on their ventilator knowledge as well?

I know some of the nurses I have come across, seem somewhat uneasy with vent management as most would say it's deferred to respiratory in the hospital.

I apologize if this is somewhat redundant, I am just genuinely curious what other paramedics think about prehospital vent management, and it's importance in relation to airway management in the field. Clearly, it isn't something that is emphasized in paramedic school, which I get, but for those who choose to go the critical care route, I cannot (IMO) stress the importance of learning proper prehospital ventilator management enough.

I still learn everyday, but can't help but feel that we as paramedics often stop once "the tube is in". This is sad, and to me further demonstrates why prehospital ETI should not be the norm for most paramedics in the field.

If any paramedics, be it critical care, or not would like to dispute this, please feel free.

 

[StCEMT]

I will throw my newbie $0.02 in.

1. No, there are obviously times it is necessary. I can think of a couple I have seen personally, however that is admittedly rare in the grand scheme of things compared to how many people I see per shift. But I have had the GCS of 3ish and a bloody mess of an airway and would definitely want anyone else like that intubated. That being said, I am also trying to read more lately on other times it truly is necessary vs I can get away with not doing it due to what I hear about poorer outcomes in some situations.

2. Absolutely. Both have helped many people avoid getting a tube. If I was on a BLS truck that was majority 911, I would definitely feel a lot better about that specific patient population knowing I had the ability to use CPAP.

3. Our ALS trucks have vents. Partially due to the fact that we do a lot of transfers and so we will be the ones transporting vent patients in the city. In those cases, we just transfer them and have all their vent settings copied (or as close as we can get) to ours then an RT signs off on it after we watch them for 5 minutes. That being said, it is also available for patients we intubate in the field. The EMT would set that up while the medic takes care of the intubation. That is something I know I do not know a lot about beyond the basics and am trying to learn more on my own. The vent was in my curriculum though. Maybe just because the trucks where my class was had vents and they wanted us to know how to use those, but we all got to go over the vents and setting them up etc. I liked having that as part of my class, while the vents where I work are different it was easy to pick up.

4. The last few patients I saw tubed didn't get an NG tube. However, I wasn't running those calls. Personally, I probably would depending on the time I had from the hospital. Especially if it was someone who had been bagged for a prolonged period of time, a drowning, etc. That being said, Remi makes a good point as well. NG/OG tubes are one of those things I will just have to see for myself since they haven't been routine with anyone I have worked with that I know of.

 

[VentMonkey]

4. The last few patients I saw tubed didn't get an NG tube. However, I wasn't running those calls. Personally, I probably would depending on the time I had from the hospital. Especially if it was someone who had been bagged for a prolonged period of time, a drowning, etc. That being said, Remi makes a good point as well. NG/OG tubes are one of those things I will just have to see for myself since they haven't been routine with anyone I have worked with that I know of.

This, I agree is subjective. Time permitting, I will place one, but it's definitely something that can wait until we get to the ED, as our main ED's we transport to have fairly short ETA's. Thanks for the feedback, @StCEMT .

 

[StCEMT]

This, I agree is subjective. Time permitting, I will place one, but it's definitely something that can wait until we get to the ED, as our main ED's we transport to have fairly short ETA's. Thanks for the feedback, @StCEMT .

Same. I have....14? hospitals within the area I work, so my transports are not very long. It would definitely be a time permitting thing.

 

[VentMonkey]

Same. I have....14? hospitals within the area I work, so my transports are not very long. It would definitely be a time permitting thing.

We have two primary hospitals we land at with helipads. One being our Level 2, the other a cardiac/ neuro ED, so unlesss we're (>) 15 minutes flight time, I soon rather wait.

In regards to vent management, I am still hyper curious to see, and hear what other paramedics feel about this aspect of airway management in the prehospital setting. Why, or why not would one think it's relevant.

 

[VentMonkey]

Though the title implies it is geared towards management of patients intubated, and placed on mechanical ventilation by the EM physician, I found this article by Dr. Weingart to be an excellent, and brief, tutorial for even prehospital providers placing their intubated patients on mechanical ventilation.

He appears to touch on all of the basics for proper initial ventilator management in the patient population, its importance, trouble shooting strategies, and things to consider.

http://emcrit.org/wp-content/uploads/2016/10/Mech-Vent-Article.pdf

 

[Carlos Danger]

At this point in this discussion, I'm just going to throw out a few thoughts based in my experience and understanding.

1. That article by Dr. Weingart is an excellent, basic overview of initial ventilation strategies.

2. In a patient with healthy lungs (i.e. the healthy 25 year old who is intubated due to a head injury suffered during an MVC) during a short transport (say, <30 min), initial ventilation strategy probably has very little effect on outcomes. As long as you maintain normoxia and normocarbia and don't cause barotrauma by using 15ml/kg in an overweight patient (as I was taught to do in my initial paramedic training), little that you do probably matters. Just keep their Sp02 over 92 and their ETco2 between 28 and 35. And don't stress too much over it.

3. Probably my biggest beef with the current trends in prehospital airway management is this: the avoidance of paralysis during the initial phases of management is completely unfounded. There is literally no downside to keeping these patients relaxed for the first hour or two of their management. It makes ventilation easier, and not having to deal with that frees up your hands and cognitive resources for other things. I find it a bit perplexing that the "progressive" folks who tend to endorse the "Roc rocks, and Succs sucks" approach tend to be the same ones who argue strongly against maintaining relaxation during transport.

4. Early NGT placement has no proven benefit, and has actually been shown to increase the probability of emesis, most likely by disruption of the lower esophageal sphincter. Once you have an ETT in place it probably doesn't matter what you do as far as emptying the gut, but understand that it isn't an important intervention by itself.

 

[VentMonkey]

Probably my biggest beef with the current trends in prehospital airway management is this: the avoidance of paralysis during the initial phases of management is completely unfounded. There is literally no downside to keeping these patients relaxed for the first hour or two of their management. It makes ventilation easier, and not having to deal with that frees up your hands and cognitive resources for other things. I find it a bit perplexing that the "progressive" folks who tend to endorse the "Roc rocks, and Succs sucks" approach tend to be the same ones who argue strongly against maintaining relaxation during transport.

Goof stuff, @Remi; would you care to elaborate further on this statement? My dividing line for induction paralytic chosen would be an isolated increase in intra-ocular pressure having Rocuronium being the more favorable one of the two. Now, obviously many can argue that the majority of closed head injuries are at risk for an increase in their intraocular pressure based on the pathology of devastating insult within the cranial vault itself, however, for the majority of our patients (i.e., those without confirmed, and/ or isolated eye injury) they will receive Succinylcholine followed by proper sedation, and pain management. Given our flight times, there is no real reason to further inhibit a neurological exam needing to be performed at the receiving facility unless there are other predetermined factors that would dictate a patient receiving the longer acting paralytics either as a pre-, or post-induction agent.

Early NGT placement has no proven benefit, and has actually been shown to increase the probability of emesis, most likely by disruption of the lower esophageal sphincter. Once you have an ETT in place it probably doesn't matter what you do as far as emptying the gut, but understand that it isn't an important intervention by itself.

I think the majority of people so far agree with this statement as well, including myself. Again, if time permits, and it doesn't seem like it will be, or pose any harm to the patient, I may placed one as a courtesy to our receiving facility. It will be placed eventually down the line, sometimes it's just easier to play nice, and act as part of the overall team in general.


Again, these are just my thoughts. While I can understand and appreciate some being apprehensive, or uncomfortable with this subject matter, I can't help but feel some degree of advanced respiratory knowledge is parallel with what is it paramedics are being taught in paramedic school. We are expected to be trained in airway management, so why just stop at proper tube placement, and confirmation? This just baffles me.

 

[Carlos Danger]

Goof stuff, @Remi; would you care to elaborate further on this statement? My dividing line for induction paralytic chosen would be an isolated increase in intra-ocular pressure having Rocuronium being the more favorable one of the two. Now, obviously many can argue that the majority of closed head injuries are at risk for an increase in their intraocular pressure based on the pathology of devastating insult within the cranial vault itself, however, for the majority of our patients (i.e., those without confirmed, and/ or isolated eye injury) they will receive Succinylcholine followed by proper sedation, and pain management. Given our flight times, there is no real reason to further inhibit a neurological exam needing to be performed at the receiving facility unless there are other predetermined factors that would dictate a patient receiving the longer acting paralytics either as a pre-, or post-induction agent.

I don't mean that patients necessarily should be paralyzed for transport; just that there is no reason to avoid it.

I know that many people view it almost as a weakness to keep patients paralyzed ("if you knew what you were doing with your vent settings and your sedation, you'd see that it just isn't necessary"), but after 15 years of vent transports in helicopters, fixed wings, and ambulances, as well as thousands of cases in the ICU and OR, I just don't agree that the disadvantages outweigh the advantages.

 

[VentMonkey]

I don't mean that patients necessarily should be paralyzed for transport; just that there is no reason to avoid it.

I know that many people view it almost as a weakness to keep patients paralyzed ("if you knew what you were doing with your vent settings and your sedation, you'd see that it just isn't necessary"), but after 15 years of vent transports in helicopters, fixed wings, and ambulances, as well as thousands of cases in the ICU and OR, I just don't agree that the disadvantages outweigh the advantages.

Yeah, I re-read the post after posting my reply, sorry about that. This is a hot-button issue currently in the critical care realm, or so it seems. Many promote less paralysis, and proper sedation/ pain management. This is what's being instilled almost anywhere I can think of, though I can appreciate, and know there are certain patient populations who may benefit from a longer acting paralytic such as respiratory failure patients who require rest from extreme muscle fatigue.

I don't know that I find it a weakness so much as a current trend. As an example, to go back to Dr. Weingart's article I posted earlier, he mentions favoring volume control assisted ventilations for the ALI/ ARDS folks, while others still emphasize more along the lines of PRVC. Though, perhaps because he is focused more on the initial settings in acute lung injured patients vs. the longer term respiratory care/ modes of ventilation needed to promote recovery, and SBT's. Nonetheless current trends, and keeping up to date with them can only benefit both the patient and the clincian, so again, I appreciate everyone's feedback.

 

[Handsome Robb]

Though the title implies it is geared towards management of patients intubated, and placed on mechanical ventilation by the EM physician, I found this article by Dr. Weingart to be an excellent, and brief, tutorial for even prehospital providers placing their intubated patients on mechanical ventilation.

He appears to touch on all of the basics for proper initial ventilator management in the patient population, its importance, trouble shooting strategies, and things to consider.

http://emcrit.org/wp-content/uploads/2016/10/Mech-Vent-Article.pdf

SIMV 500VT 12RR Peep of 5 FiO2 1.0?

[emoji13]


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[VentMonkey]

SIMV 500VT 12RR Peep of 5 FiO2 1.0?

[emoji13]


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I LOL-d at this post pretty hard.

 

[Tigger]

SIMV 500VT 12RR Peep of 5 FiO2 1.0?

[emoji13]


Sent from my iPhone using Tapatalk

Pretty much what our vent protocol is sadly. I am happy to have a vent for long transports, but I know next to nothing about vent management. I'm trying to educate myself, but am also hampered by the ParaPac which is fairly limiting. Tidal volume, frequency, 100% or 50% O2, and maximum inflation pressure are the only things I can set. I don't even know what to do with the max inflation pressure.

 

[VentMonkey]

I don't even know what to do with the max inflation pressure.

While I am not familiar with this particular ventilator, nor am I an RT, I'm guessing it's an (mean) airway pressure reading/ alarm.

If so, most patients should not go above 30, however, certain conditions (e.g., ARDS, and/ or burn patients) may dictate slightly higher pessures.

 

[StCEMT]

Pretty much what our vent protocol is sadly. I am happy to have a vent for long transports, but I know next to nothing about vent management. I'm trying to educate myself, but am also hampered by the ParaPac which is fairly limiting. Tidal volume, frequency, 100% or 50% O2, and maximum inflation pressure are the only things I can set. I don't even know what to do with the max inflation pressure.

Same vent I have. Want to learn more as well, because I just dont know enough to know how this vent is limiting. Well except with an assist setting, I had a transport who we couldn't put on that setting.