ET vs laryngeal tube Pragmatic Airway Resuscitation Trial abstract

Maybe I missed it, but do they identify what was used versus ET? King, LMA, or what?
 
rescue1 said:
...presumably by physicians with more airway experience than paramedics...
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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.
 
rescue1 said:
presumably by physicians with more airway experience than paramedics.
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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
 
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.
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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.
 
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.
 
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.
 
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.

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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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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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).
 
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.
 
rescue1 said:
ALS trauma care may potentially be harmful but the data is just a bunch of retrospective studies
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rescue1 said:
, and for every study that shows that ALS care saves lives, there's another one that says it doesn't.
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Shouldn't we err on the side that in the absence of known benefit, it's better to *not* change practice?
 
EpiEMS said:
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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A similar principle would be: in the absence of a known benefit, it's better to do the less radical/less invasive intervention.
 
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.
 
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.
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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...
 
EpiEMS said:
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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That is a rational approach IF you have good reason to believe that the intervention in question (ETI, in this case) actually works.
 
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...
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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.
 
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.
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I meant more like “why did we ever start doing field ETI in the first place” without evidence.
 
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.
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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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