# ET vs laryngeal tube Pragmatic Airway Resuscitation Trial abstract



## medicsb (May 16, 2018)

https://www.eventscribe.com/2018/SAEM/agenda.asp?h=Plenary&BCFO=PL

Results: Of 3,005 enrolled patients, 1,506 were assigned to initial LT and 1,499 to initial ETI. Patient characteristics were similar between treatment arms. Seventy-two hour survival was significantly higher for LT than ETI: 18.2% vs 15.3%, adjusted difference 2.9% (95% CI: 0.2-5.6%), p < 0.01.Secondary outcomes were significantly better for LT than ETI: ROSC 27.9% vs. 24.1%, p=0.02; hospital survival 10.8% vs 8.0%, p=0.01; favorable neurological status at discharge 7.0% vs 5.0%, p=0.02. There were no significant differences in oropharyngeal or hypopharyngeal injury, airway swelling, or pneumonia or pneumonitis.

Conclusions: In this multicenter pragmatic clinical trial in adult OHCA, initial LT was associated with significantly better clinical outcomes than initial ETI. EMS providers should consider a strategy of initial LT in adult OHCA.


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## Bullets (May 16, 2018)

this is the second place ive seen this study mentioned, though the results were not discussed, based on the OPs language i assumed it showed a better outcome with a LT than an ET. My question then and now is, can we be certain the difference in that survival was directly due to the placement of a LT and not any of the dozen or so factors that affect how a OHCA is conducted. I have numerous questions regarding the methodology and criteria chose fro this study. Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"


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## Summit (May 16, 2018)

I think Wang et al were trying to do a prospective controlled trial to answer the presumed biases confounding their previous retrospective observational study https://www.ncbi.nlm.nih.gov/pubmed/22664746

That this new controlled study had opposing results indicates prima facie indicates the assumption of observational bias were valid.



Bullets said:


> My question then and now is, can we be certain the difference in that survival was directly due to the placement of a LT and not any of the dozen or so factors that affect how a OHCA is conducted.  I have numerous questions regarding the methodology and criteria chose fro this study.


Yes... it will be interesting to see the methods and controls used



> Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"



With respect, you need to consider your definition of "significantly better" both in terms of statistics and human life! When we are talking about evidenced based study, significantly better means "the statistical analysis indicates that the difference in outcomes between intervention groups is likely due to the intervention rather than random chance (reject null)." 

That 7% LT patients were discharged with favorable neuro outcomes can be reliably attributed (98% chance) to being in the LT group vs ETI group (5%) vs the difference being due to random chance (2% or p=0.02). That IS significant  statistically, and if the difference is not otherwise explained by confounding variables or bias, it is very meaningful for practice... to the tune of *40% improvement in outcomes!!! If 40% improvement in favorable neuro outcomes isn't meaningful, what is?*


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## Carlos Danger (May 16, 2018)

Bullets said:


> Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"



Are you serious? SIXTY MORE PEOPLE out of 3,000 had a favorable neurological outcome.....SIXTY PEOPLE.....and you arent sure that is significant?

We can certainly debate the methodology here (once we see the full text), but these stats are definitely significant, both statistically and clinically.


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## Bullets (May 16, 2018)

http://www.eventscribe.com/2015/app...hare.asp?sfp=NDg4Nnw2NTE5Njh8MjA0NDA0NDN8LTE=

Heres the presentation


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## NomadicMedic (May 16, 2018)

That’s another nail in the coffin of ETI for the occasional intubator. 

And I can’t say that I’m upset about it.


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## EpiEMS (May 16, 2018)

Good to see people critically reevaluating their prior findings. 

Not surprised that ETI fell below LTs, particularly given the user error factor.


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## Summit (May 16, 2018)

Bullets said:


> http://www.eventscribe.com/2015/app...hare.asp?sfp=NDg4Nnw2NTE5Njh8MjA0NDA0NDN8LTE=
> 
> Heres the presentation


Thank you. Wow. Pretty elegant study!

Looks robust (multicenter randomization WITH crossover)... well controlled... comparable groups... interesting datapoints: ETI took 23% longer to get a good airway, only 51.3% initial success of ETI. Obviously missing a few details and I'm uncertain if this has been peer reviewed yet?


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## Old Tracker (May 17, 2018)

Just a post to be notified of new comments. Interesting stuff.


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## StCEMT (May 17, 2018)

Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?


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## Summit (May 17, 2018)

StCEMT said:


> Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?


It wasn't in the presentation... but all the preoxygenation data I know is for people who are NOT in cardiac arrest.

I am not aware of any evidence for improved outcomes from preoxygenation DURING CARDIAC ARREST prior to ETI. Why would it? Hands off and you aren't circulating the oxygenated blood. Plus, preoxygenation is hard when you have to pause compressions to hyperventilate with the BVM... so then you are left with putting a HFNC under the BVM... or NRB and continuous compressions... I mean you could do some trials but I'm not seeing a strong rationale why this would change for ETI vs LT (you'd do it for both groups). 

I speculate hands off time is probably the the biggest contributor to the differences in outcomes, and that wouldn't change with preoxygenation. This study found that repeat attempts lead to statistically more >10sec compression pauses with ETI vs any other airway management strategy. We saw that the ETI group saw 2 or more attempts in almost half the cases. We can surmise more compression interruptions.

Meanwhile, we do know that ETI early during IHCA also has worse outcomes vs delayed (despite probably having more practiced intubators) and that video lyngoscopy doesn't decrease hands-off-chest time.

So what if you "preoxygenate" as above and then try to intubate while doing compressions? You are moving tidal volume with compressions and eliminating your preoxygenation nitrogen washout... and compressions make intubation harder so lower initial success rates. I'm not aware of any trials involving intubation during compressions. Interesting, but you are posing a completely separate intervention to be trialed.


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## Carlos Danger (May 17, 2018)

Interesting. Has it been published?

This time the results can't be blamed on the lousy SoCal EMS systems.


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## StCEMT (May 17, 2018)

@Summit my preoxygenating question is because I respond to bystander CPR a fairly decent amount. If they have been doing compressions, blood has circulated, oxygen is reaching tissue, etc. I don't know how much. Maybe someone smarter than me can ball park it, but I don't particularly care at that point in time either. I just want to make sure I have solid ABC's immediately and I tend to blanket stuff like that simply for the sake of having a consistent routine that covers the important things.

I agree that hands off time probably has a larger role, but that makes me want to know how many people in this study stop compressions to intubate. It isn't necessary and I've found with taking time to prepare, it is easy to do. All it is are the same steps we should already be taking with maybe a little extra padding.

Anecdotal, but I have intubated 3 cardiac arrest this month. Initially successful on each using a mix of VL and DL. I don't have a timer for them, but it was pretty close to our practice runs, they were all very easy. Only one had delay and that was RIGHT before intubating due to vomiting and then suctioning, not inability to find landmarks.

Now admittedly the survival of those are 0/3. 2/3 I didnt think had a chance from the start. One was an unwitnessed arrest with likely a significant downtime. The other a multiple GSW turned arrest that I only worked because my notes made it sound like he was alive when the shooting was done, but that wasn't a certainty. I had doubts, so I worked it, but would have been completely justified in calling it on scene. I had 1/3 that maybe would have had a chance. I didn't intubate until about 10 minutes in after suctioning the vomit. What would have had more of a negative effect is the interruptions I had with autopulse failures and having to tell the FF's to get on to manual compressions. The intubation itsself though was done during compressions with fairly little time spent actively using the laryngoscope.

Now I realize my current recent calls are 0.001% of this study. Nor are all intubation attempts as easy as these. However, I have been very successful lately at intubating while CPR is being done and I credit that all to putting most of my effort into preparation before I even pick up a laryngoscope.

I can't deny the significance of the numbers this study had such as first pass success, etc. and what it says about our skills as a whole. The results arent flattering. I don't think it's wrong to question our use of intubation, I just want to know the method behind how it's done in the studies and if places that put a heavy emphasis on strong airway management ability (and the numbers to back it) have similar results.


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## Summit (May 17, 2018)

@StCEMT interesting... I looked briefly for any data on intubation during compression, didn't find any. It would be interesting to see some. Similarly, I don't see why one would have to interrupt compression to place a SGA...


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## Bullets (May 17, 2018)

StCEMT said:


> Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?


In the last slide or two the specifically say they have no data on CPR quality. Certainly an issue. I also want to know what the normal ET volume is for these agencies. Are these agencies that normally have issues or low frequency intubating? 3/4 of the reasons they give for ET failure can be remedied with practice and experience. I agree that what this study shows is that intubation is a highly perishable skill, and if the agency isnt going to make the effort to get their providers time on the blade, they should give it up for an LT

Like you ST, i work in an area that has and does a lot of intubation. My unit had 7 opportunities to intubate in April, we (my partner and i) had a first pass success rate on 6 of them, and 1 was a traumatic arrest we didnt work. Our unit averages about 7 tubes a month on 15ish night shifts. We get a ton of opportunities to intubate, and there is a difficult airway manikin set up for practice 24/7 in station. Yet with those 7 tubes, 1 survived with reasonable neuro fuction and only 2 were actually alive when we arrived. On the surface our survival numbers look like garbage


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## StCEMT (May 17, 2018)

@Summit it would be interesting to see. Again, limited experience/numbers, but comparing my success in 2017/2018 is already a night and day difference. I don't know what my '17 numbers were, but I wasn't good. I took a lot of time to reevaluate what I was doing right and wrong then made a lot of little adjustments and it's a night and day difference.

The only two good neuro outcomes I have had I attribute to two things I know for sure both had. Bystander CPR and immediate defibrillation on arrival. I never even had IV access on the last one that's how little we made it through the arrest algorithm before getting a pulse.

But even then, you're right. An SGA would not require interruptions in CPR either.

@Bullets ah, I missed that part. I have a feeling there likely are many instances of that happening. Maybe the difference between compressions + SGA vs ETT isn't significant, but that's expecting that everyone is proficient.

Out of all those you had though, what are the numbers on the other important things? Witnessed? Bystander CPR? Down time? That being said, I do agree with you. If the departments aren't supported their medics skills in this regard, do away with the intubation. My old department was straight to an igel and I absolutely loved the using it.


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## Summit (May 17, 2018)

Well now it has hit the University Press Release stage... still don't know if its peer reviewed?

10,000 lives!!!!!!
https://news.ohsu.edu/2018/05/16/em...064008&l=2772_HTML&u=1485357&mid=7304584&jb=0


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## medicsb (May 17, 2018)

Summit said:


> Well now it has hit the University Press Release stage... still don't know if its peer reviewed?
> 
> 10,000 lives!!!!!!
> https://news.ohsu.edu/2018/05/16/em...064008&l=2772_HTML&u=1485357&mid=7304584&jb=0



If it hasn't yet been formally peer reviewed, it will be.  This will be published.


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## Bullets (May 17, 2018)

StCEMT said:


> Out of all those you had though, what are the numbers on the other important things? Witnessed? Bystander CPR? Down time? That being said, I do agree with you. If the departments aren't supported their medics skills in this regard, do away with the intubation. My old department was straight to an igel and I absolutely loved the using it.


None of my OHCAs were witnessed. Of the 4, 2 we're in nursing homes with unknown down times and SNF quality CPR...The other two were at home, downtimes of an hour or so, CPR instructions over the phone

The two who were alive, both were RSI, one ended up being a massive cerebral hemorrhage that prolapsed. The one who survived was a trauma fall with a closed head injury. That patient did ok at the trauma center.

Id also like to see the breakdown by type of airway device. Did the iGel perform well? What we're the various tubes?


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## rescue1 (May 17, 2018)

To stir the pot a little, here's a study that also shows poorer outcome for IN-hospital cardiac arrests who were intubated within 15 minutes of arresting, presumably by physicians with more airway experience than paramedics. However, its data from 2000-2014, and I feel like the focus on compressions over airway didn't really appear until the end of that study period.

https://jamanetwork.com/journals/jama/fullarticle/2598717


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## Old Tracker (May 18, 2018)

Maybe I missed it, but do they identify what was used versus ET? King, LMA,  or what?


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## Summit (May 18, 2018)

Old Tracker said:


> Maybe I missed it, but do they identify what was used versus ET? King, LMA,  or what?


King


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## Old Tracker (May 18, 2018)

Summit said:


> King



Thank you.


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## Peak (May 19, 2018)

rescue1 said:


> ...presumably by physicians with more airway experience than paramedics...



I wouldn't put money on that. I only skimmed the article but unless they are accounting for provider experience level I would be dubious. There is a difference between experienced ED docs, intensivists, and anesthesia intubating compared to the third year internal med resident.


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## Bullets (May 19, 2018)

rescue1 said:


> presumably by physicians with more airway experience than paramedics.



This is highly location based. I have worked units where the ER calls the medics the the hospital to intubate as the on call physician has little experience intubating


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## Carlos Danger (May 19, 2018)

Peak said:


> I wouldn't put money on that. I only skimmed the article but unless they are accounting for provider experience level I would be dubious. There is a difference between experienced ED docs, intensivists, and anesthesia intubating compared to the third year internal med resident.



It doesn’t matter if the in-hospital study includes intubators of varying skill levels. It is probably a fair assumption that most of the intubators in the hospital are quite skilled, while some are not. The abstract posted by the OP doesn’t appear to take experience level into account either.


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## rescue1 (May 20, 2018)

The second study has such a pretty huge dataset that appears to be from larger academic hospitals, and unfortunately it doesn't account for success rate. However, like Remi said, I would be shocked if the aggregate first pass success from in hospital intubation was lower than the 55% first pass seen in the prehospital study. Obviously we can't know that for sure, but my point was it may suggest that maybe the act of intubating itself is harmful early in arrest, as opposed to the lack of skill of the intubator (which is what everyone says about these prehospital studies that usually show ****ty first pass success).  

Of course, it could also be saying that in the years between 2000-2014, we stopped compressions a lot to tube patients, which anecdotally seemed to happen a lot more when I started EMS than it does now.


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## Peak (May 21, 2018)

It's not just a matter of success rate but also how long it takes to place the tube. Newer clinicians who are being trained or training others will generally take longer than those who are working independently with good experience. 

I worked in a large, level I trauma, university affiliated, teaching hosptial for a long time and things just took much longer than in my current non-university affiliated limited teaching center (we have a few residents who rotate through but are not allowed in the EDs or ICUs). I don't think that the success rates for intubation are very different between the two (they are not between the EDs and PICUs), but we are certainly much quicker. There is more to good intubation than just what a clinicians success rate is.

I'm not trying to disparage the studies, but I wouldn't put all of my eggs in the basket of blind airways. I think that they are a good tool to have, but like all tools they have conditions in which they are the best and those in which they are not. There are also may practices that we initially changed based on new data, and then shortly changed back based on a subsequent study.

Also having worked in a large teaching hospital I learned that a lot of the published research may not have the greatest methods (much of which is simply due to how the practice of medicine works and not the fault of the researchers), and that we should examine them very closely before making practice changes. The current literature shows no statistical benefit to cooling pediatric post-arrest patients, and yet most of the large pediatric systems still do it because we all recognize the limitations in the study that was published and the potential benefits that we see in both adults and neonates.


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## Carlos Danger (May 21, 2018)

Peak said:


> It's not just a matter of success rate but also how long it takes to place the tube. Newer clinicians who are being trained or training others will generally take longer than those who are working independently with good experience.
> 
> I worked in a large, level I trauma, university affiliated, teaching hosptial for a long time and things just took much longer than in my current non-university affiliated limited teaching center (we have a few residents who rotate through but are not allowed in the EDs or ICUs). I don't think that the success rates for intubation are very different between the two (they are not between the EDs and PICUs), but we are certainly much quicker. There is more to good intubation than just what a clinicians success rate is.
> 
> ...



The results of a large, well-designed, prospective study should stimulate practice change - or at least the serious consideration of it - when it echos the results of previous retrospective studies and especially when the current practice in question has never been shown to improve outcomes anyway. It isn't as though we know intubation is good for patients in these scenarios and this study is flying in the face of what others have shown.

More than any other area of medicine that I am aware of, EMS has a very strong tendency to embrace research that confirms current culture, while finding reasons to reject research when it doesn't support what we want to do. Current practices in EMS airway management are the best example I can think of.


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## Peak (May 21, 2018)

You always have to be skeptical of research, people have inherent bias and there will always be flaws in studies. I'm not saying that the results are going to be wrong or that there shouldn't be a change in practice, but if you are going to look at studies you must do so through the eyes of a scientist rather than a casual observer. There is a reason why good studies have published limitations and the recommendations almost always include further research, they shouldn't be making sweeping recommendations for practice changes. Generally speaking practice changes should only come through meta-analyses of multiple, high quality, peer reviewed, RCTs; though of course this is limited by our desire to provide the best medical practice in the shortest period of time.

What were the times to ROSC, time for transport from scene to hospital, time to initiation of body cooling, time to cath lab, average troponins, average days intubated in the unit, average arterial PHs, et cetera? If we adjusted to a similar success rate for intubation would a blind airway still show benefit? Would have even better outcomes by making initial attempts better through the use of video laryngoscopy or even basic things like using a bougie? Did the number of ET tubes placed in the past year by individual providers have a statistical difference in outcomes?

I honestly have no interests in preserving intubation in EMS. I do have an interest in good patient outcomes, and the idea that some EMS providers have that all codes need to be tubed is highly flawed. I also don't think that we can make a blanket statement that kings, igels, or whatever the next flavor of the month will be (since it used to be EOAs and combitubes at one point; are there still a push by some do only do passive oxygenation during codes) should be used as the primary form of airway management. Airway management is complex and in my opinion not well enough studied and practiced by most prehospital providers (in fact most medical providers).


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## rescue1 (May 22, 2018)

You have to look at research skeptically and logically, sure, but it's also to important to remember that good research is hard, and it takes a long time, and even then it might not be completely generalizable. We can (and should) continue to study airways, but the fact remains that the data still sits pretty heavily on the side of the SGAs for this one. You can always demand more data from a study because no study will ever have the size to effectively measure all the different variables for a given medical condition. And to be honest, even if there was no difference between ETT and SGA when you controlled for first time pass success, the fact that it was only 55% in this giant cohort of agencies (which include non-fire "high speed" places like Ottawa and Toronto EMS, Pittsburgh EMS, etc, even if it also includes places like Dallas Fire-Rescue) is pretty upsetting. That being said, I don't think you'll see ETTs vanishing off trucks tomorrow. But I wouldn't be surprised if this is the beginning of the end. Of course, five years later who knows, will they be like MAST trousers and stay dead, or will they come back with different parameters? Who knows. At some point we have to accept the uncertainty and say "this is probably correct given what we know now". 

And lets be real, airways and cardiac arrests are pretty well studied and implemented compared to other things we do in EMS. Spinal immobilization is, if anything, thought to be harmful. ALS trauma care may potentially be harmful but the data is just a bunch of retrospective studies, tPA and "the stroke window" for large vessel occlusion still churns up a lot of debate between EM and neuro docs (and that is actually well studied), and for every study that shows that ALS care saves lives, there's another one that says it doesn't. Unfortunately we still have a long way to go with EMS (really emergency medicine in general) and research.


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## EpiEMS (May 22, 2018)

rescue1 said:


> ALS trauma care may potentially be harmful but the data is just a bunch of retrospective studies





rescue1 said:


> , and for every study that shows that ALS care saves lives, there's another one that says it doesn't.



Shouldn't we err on the side that in the absence of known benefit, it's better to *not* change practice?


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## Summit (May 22, 2018)

EpiEMS said:


> Shouldn't we err on the side that in the absence of known benefit, it's better to *not* change practice?



A similar principle would be: in the absence of a known benefit, it's better to do the less radical/less invasive intervention.


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## Bullets (May 22, 2018)

Even if this study shows that ET dont provide any benefit to SCA, what are we really talking about ? 1% of an agencies call volume? Less than if they are not a tiered system. My project could turn to us tomorrow and say SCAs get iGels, period, and we wouldn't change anything about how we are equipped, because we still need ETs and use them far more often for airway compromise and clinical course than we ever see SCA.


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## EpiEMS (May 22, 2018)

Summit said:


> A similar principle would be: in the absence of a known benefit, it's better to do the less radical/less invasive intervention.


I had a whole list of decision rules, but deleted it - too much writing 

In general, I'd agree - if we don't know the benefit & cost is high, safer to not do it. (If the cost is low, we might want to consider it.)

I would think a lot of possible field interventions fall into this unknown benefit/high cost (at least, economic cost) classification - namely field CT scans...


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## Carlos Danger (May 22, 2018)

EpiEMS said:


> Shouldn't we err on the side that in the absence of known benefit, it's better to *not* change practice?


That is a rational approach IF you have good reason to believe that the intervention in question (ETI, in this case) actually works.


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## rescue1 (May 22, 2018)

EpiEMS said:


> I had a whole list of decision rules, but deleted it - too much writing
> 
> In general, I'd agree - if we don't know the benefit & cost is high, safer to not do it. (If the cost is low, we might want to consider it.)
> 
> I would think a lot of possible field interventions fall into this unknown benefit/high cost (at least, economic cost) classification - namely field CT scans...




I think in 5 years we'll think mobile stroke ambulances are huge wastes of money, especially the ones I've seen. They have one by me in Manhattan, where there are, count them, 13 stroke centers in 23 square miles.

And obviously I'm not advocating for getting rid of paramedics and replacing everyone with $10/hr basics. I'm just saying we do a lot of things without good evidence, so while it's good question studies that may radically change management, it's also good to remember that we should also be that skeptical about everything we do. If this study showed that paramedic intubation caused a 10% increase in survival, I bet many people would look much less critically at the data since it's all positive news for EMS. 

As for what Bullets said, I don't know about his system but I would bet that 90% of our tubes are on arrest patients, and we tube relatively successfully. If this turns out to be a practice changing study then I'm not sure if my service could justify keeping ETTs on the truck because of how infrequently they'd be used.


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## EpiEMS (May 22, 2018)

Remi said:


> That is a rational approach IF you have good reason to believe that the intervention in question (ETI, in this case) actually works.



I meant more like “why did we ever start doing field ETI in the first place” without evidence.


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## rescue1 (May 22, 2018)

EpiEMS said:


> I meant more like “why did we ever start doing field ETI in the first place” without evidence.



"I don't really know if it works, but it I guess it SHOULD" describes like how 90% of medical interventions/drugs got started.


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## Bullets (May 23, 2018)

rescue1 said:


> As for what Bullets said, I don't know about his system but I would bet that 90% of our tubes are on arrest patients, and we tube relatively successfully. If this turns out to be a practice changing study then I'm not sure if my service could justify keeping ETTs on the truck because of how infrequently they'd be used.



If you are successful as an agency at intubating, why would you get rid of ETTs. While this study shows better outcomes with the LTs, i dont think its because of the physical plastic tube. My takeaway from this is that people who have low exposure and opportunity to intubate stink at it, and that delay of a an airway is what causes the poorer outcomes.

As far as my agency goes, "Expected clinical course" is a big point of emphasis for our MD and the hospitals. They very much emphasis that if we think this patient is going to get intubated in the hospital, then knock them down in the field.


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## Carlos Danger (May 23, 2018)

Bullets said:


> If you are successful as an agency at intubating, why would you get rid of ETTs. While this study shows better outcomes with the LTs, i dont think its because of the physical plastic tube. My takeaway from this is that people who have low exposure and opportunity to intubate stink at it, and that delay of a an airway is what causes the poorer outcomes.



I think it's quite clear that a big part of the reason that the research is so unsupportive of prehospital intubation is the fact that most paramedics just aren't very good at it because they don't do it very often. But there's more to it than that, as this study indicates. 


Bullets said:


> As far as my agency goes, "Expected clinical course" is a big point of emphasis for our MD and the hospitals. They very much emphasis that *if we think this patient is going to get intubated in the hospital, then knock them down in the field.*



Even if one were to assume that prehospital intubation is beneficial as opposed to the alternatives (a claim which has never been proven despite many attempts), how could one possibly think that just because a patient might have a critical procedure performed in the hospital later on, that they are automatically better off having that critical procedure done in a setting with much less expertise and resources?


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## rescue1 (May 23, 2018)

I was just responding to your comment that you get more of your tubes from non-arrest patients--most of our tubes (no real RSI in Pennsylvania) are arrests.

Unfortunately this study doesn't address the effect of 1st time success with ETTs, so for now we have no idea what change that would have. To be honest, I'm suspicious any large study like this will ever show significant superiority--we all talk about how our first pass success rates are 80, 90% on the internet, but outside of physicians and helicopter EMS most ground medics in big urban departments have much lower success rates, in the 40-60% range. I did research with a big southern US fire department's cardiac arrest data and they had like a 45% first pass success. They've since switched to SGAs first line for arrests, but it was pretty eye opening. That's what prompted me saying that we'd have to take the tubes off the truck at my service if SGA became standard of care--if you lose 80% of your intubations there's no way you can stay competent.

I think in the future we'll see intubation move from a skill all paramedics have to a skill reserved for "advanced care" paramedics who have the opportunity to intubate more regularly and therefore be more proficient at it. Or in urban systems, where the hospital is less than ten minutes away, it may not make sense to have prehospital intubation at all.


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## FiremanMike (May 24, 2018)

Summit said:


> It wasn't in the presentation... but all the preoxygenation data I know is for people who are NOT in cardiac arrest.
> 
> I am not aware of any evidence for improved outcomes from preoxygenation DURING CARDIAC ARREST prior to ETI. Why would it? Hands off and you aren't circulating the oxygenated blood. Plus, preoxygenation is hard when you have to pause compressions to hyperventilate with the BVM... so then you are left with putting a HFNC under the BVM... or NRB and continuous compressions... I mean you could do some trials but I'm not seeing a strong rationale why this would change for ETI vs LT (you'd do it for both groups).
> 
> ...



The folks in Rialto studied apneic oxygenation via high flow cannula in the minutes leading up to intubation in OHCA.  I believe their algorithm has them stop BVM ventilation after moving the patient from the floor to the cot, and then resume once an airway is placed.

I’m impressed with their study, primarily because they include all cardiac arrest data and not just the mythical Utstein arrest.  I’m also impressed with the above linked ETI study and will be discussing it with my medical director.


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## FiremanMike (May 24, 2018)

rescue1 said:


> I was just responding to your comment that you get more of your tubes from non-arrest patients--most of our tubes (no real RSI in Pennsylvania) are arrests.
> 
> Unfortunately this study doesn't address the effect of 1st time success with ETTs, so for now we have no idea what change that would have. To be honest, I'm suspicious any large study like this will ever show significant superiority--we all talk about how our first pass success rates are 80, 90% on the internet, but outside of physicians and helicopter EMS most ground medics in big urban departments have much lower success rates, in the 40-60% range. I did research with a big southern US fire department's cardiac arrest data and they had like a 45% first pass success. They've since switched to SGAs first line for arrests, but it was pretty eye opening. That's what prompted me saying that we'd have to take the tubes off the truck at my service if SGA became standard of care--if you lose 80% of your intubations there's no way you can stay competent.
> 
> I think in the future we'll see intubation move from a skill all paramedics have to a skill reserved for "advanced care" paramedics who have the opportunity to intubate more regularly and therefore be more proficient at it. Or in urban systems, where the hospital is less than ten minutes away, it may not make sense to have prehospital intubation at all.



I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm  got a fair amount of exposure to medics who are “good” at intubating and those who aren’t.  From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..


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## Summit (May 24, 2018)

FiremanMike said:


> I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm  got a fair amount of exposure to medics who are “good” at intubating and those who aren’t.  From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..


Exactly. And if the counter is, "well if they'd JUST studied really practiced and competent intubators as a group, maybe it would have been different," such results would STILL support the idea of restricting and reducing who can do ETI. 

There is no way to make most paramedics experienced and practiced intubators. There are around 70K MDA/CRNA/AAs in the US but over 200K paramedics.


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## FiremanMike (May 24, 2018)

Summit said:


> Exactly. And if the counter is, "well if they'd JUST studied really practiced and competent intubators as a group, maybe it would have been different," such results would STILL support the idea of restricting and reducing who can do ETI.
> 
> There is no way to make most paramedics experienced and practiced intubators. There are around 70K MDA/CRNA/AAs in the US but over 200K paramedics.



I do think it's POSSIBLE to make paramedics competent at intubation, even if they aren't getting them on actual runs.  The problem is, it's not practical from a financial standpoint and would also require a larger off-duty time commitment than most medics would be willing to invest.

It also doesn't help that our training tools are terrible at best.  Why these large simulations companies refuse to develop a realistic airway trainer is beyond me.  Real airways don't move like that, ever.


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## rescue1 (May 24, 2018)

FiremanMike said:


> I’d be willing to bet that with a sample size of 3000 patients where the treatment arms rotated equally at 3 month intervals, the ETI arm  got a fair amount of exposure to medics who are “good” at intubating and those who aren’t.  From the abstract, I think this study did a pretty good job of trying to even out the confounding factors..



Yeah the only factor that wasn't controlled for was first pass success. So of the 1,500 ETT patients, about 800 had the tube on the first try, but the abstract has no data if those patients did better than the 700 who needed a second attempt/rescue airway. Hopefully it'll be in the final full publication. 

Either way, like Summit said, I don't think there's a universe where paramedics as a national group are super great an intubating because there are so many paramedics and only a certain amount of intubation to go around.


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## FiremanMike (May 25, 2018)

rescue1 said:


> Yeah the only factor that wasn't controlled for was first pass success. So of the 1,500 ETT patients, about 800 had the tube on the first try, but the abstract has no data if those patients did better than the 700 who needed a second attempt/rescue airway. Hopefully it'll be in the final full publication.
> 
> Either way, like Summit said, I don't think there's a universe where paramedics as a national group are super great an intubating because there are so many paramedics and only a certain amount of intubation to go around.



Personally, I'm OK with 'first pass' success rate being uncontrolled, as I think it means this data is a more accurate representation of real life conditions.


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## rescue1 (May 25, 2018)

Yeah I meant as like a secondary data point. We're never going to see 100% success with paramedic intubation, but it would be nice to see if perfectly placed ETT tubes were better/the same/still worse than SGAs, even if it was just out of curiosity.


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## StCEMT (May 30, 2018)

Just throwing this out for fun.


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