Intubations dissapearing?

[Smash]

Putting in ETT tube stops aspiration, whether it be vomit blood or what not

Actually it is a common error to think that ETI prevents aspiration. It certainly reduces the likelihood of massive aspiration, however as near as makes no difference to 100% of intubated ICU patients have gut flora in their lungs. This is why it is important to pass an orogastric tube (amongst other reasons) in the intubated patient and to remain vigilant about suctioning not just the tube but also the oropharynx.

 

[timmy84]

My ambulance service is looking into a device called the "S.A.L.T." (click here for link to its website) it is inserted like an OPA and can be used as an OPA....but when it is time to intubate, the ET tube is slipped into a hole in the "S.A.L.T." and the tube is almost always guided into the trachea...The tube would then be confirmed by normal methods and restrained by the usual methods as well...
I deffinately see this being used in the near future as well...

I was just reading about the S.A.L.T (or SALT for anyone searching without the periods) today. One of my instructors mentioned it about a week ago, and was not able to fully describe it, so I assume it is not all the way out there. Seems like a pretty good product, I wanted to know if anyone has used it. What are everyone's thoughts about it? It certainly looks like it could be cost effective, or will be once it's patent expires (a CombiTube costs our service 50 bucks, versus 3 bucks for an ETT) (wow I am sounding like my boss).

 

[usafmedic45]

Hmmmm..... I may be misreading it, but that seems like an awful lot of hostility.

That you are. I might be a little more bristly than normal (and ask to be forgiven that due to a lot of the crap going on my personal life at the moment), but it's not frank hostility you're encountering. Just my blunt nature combined with having been up for far too long.

Are you a personal friend of Dr Wang's?

Actually no, I've never met the man nor spoken with him in any way so I can't count him as a friend or even an acquaintance, however I do tend to agree with a lot of what he (and nearly every other researcher on the topic) has said. Not all of it, but I think he's gotten at least the broader gist of things fairly close to correct.

The vast majority of studies into prehospital ETI tell us very little for a number of reasons, not least of which is the fact that so many are retrospective.

OK, two things:

1. Ever tried to squeeze a prospective airway study past an IRB before? It's not easy, I should know...I've tried on two different occasions. You start talking about giving people "differing" (even if the end result of the two devices is effectively the same thing) levels of care and they start to have fits about it, especially when you're talking about doing it under implied consent. Do a literature review of some of the issues regarding community participation, consent issues, etc in cardiac arrest research and you'll see part of what I'm talking about.

2. You can't throw out a study simply because you don't like the fact that it's retrospective. It's akin to saying you're not willing to be told you messed up a case when your medical director calls you on it at audit and review because it's done retrospectively.

Actually that particular study does tell us a lot about whether intubation has a potential for benefit in the field. The fact that a lack of protective airway reflexes in the field (read as: #1 indication for prehospital intubation short of "patient not breathing") correlates with poor outcomes indicates that despite aggressive airway measures, we can't do a lot for them. That coupled with poor success rates (which are documented elsewhere ad nauseum) for prehospital intubation it would lead a reasonable person to go, "Hmm...maybe there is a way we can achieve the same ends in patients (proper oxygenation, ventilation, etc) and not have the risks associated with field intubations....". I agree that there needs to be more research done, but I'm afraid given the increasingly retentive nature of IRBs towards human clinical research under implied consent it'll take a miracle (or some well placed bribes) to see it carried out at least in the US.

This is why I advocate further research before we throw the baby out with the bathwater.

I am always game for more research, but I also see the other side of the issue that says why not use an easier option that delivers the same results with fewer risks? At very least until we settle the issue with more definitive research that would seem to be the more patient safety oriented thing to do.

It is no use comparing, for example RSI in head injured patients with cold ETI.

Agreed, at least in part. It would be interesting to see how the two stack up in comparison, but you're right if we're going to settle the issue those need to at least be separate arms of a study and not lumped together.

I'm not sure why you think this means I have a large ego, or indeed that I want to make my penis larger (I'm not sure why you think I have a penis at all in fact) but, if that is you see things, so be it.

It's just the way your previous post came across. Kind of like how you read my response to be hostile, I read yours as having the same attitude I've encountered numerous times in person from EMTs and paramedics whenever the issue of downplaying intubations comes up. For that you have my apologies.

By the way, I like how you handled the aspiration issue. Well done.

 

[Smash]

OK, two things:

1. Ever tried to squeeze a prospective airway study past an IRB before? It's not easy, I should know...I've tried on two different occasions. You start talking about giving people "differing" (even if the end result of the two devices is effectively the same thing) levels of care and they start to have fits about it, especially when you're talking about doing it under implied consent. Do a literature review of some of the issues regarding community participation, consent issues, etc in cardiac arrest research and you'll see part of what I'm talking about.

Try getting permission to run a trial on epi versus placebo in cardiac arrest, despite the lack of hard data that epi is any use and the ever-present and mounting data that it may be detrimental. It's nearly impossible to get withing 200 feet of the building! Fortunately though we have our Antipodean cousins to cover for us. Bernard, who has published a number of papers on pre-hospital stuff is due to publish a real prospective trial on prehospital versus in hospital RSI in traumatic brain injury, and I have been told that the results are very, very promising. I wait with bated breath and the hope that we are not let down by substandard study design.

2. You can't throw out a study simply because you don't like the fact that it's retrospective. It's akin to saying you're not willing to be told you messed up a case when your medical director calls you on it at audit and review because it's done retrospectively.

Actually that particular study does tell us a lot about whether intubation has a potential for benefit in the field. The fact that a lack of protective airway reflexes in the field (read as: #1 indication for prehospital intubation short of "patient not breathing") correlates with poor outcomes indicates that despite aggressive airway measures, we can't do a lot for them. That coupled with poor success rates (which are documented elsewhere ad nauseum) for prehospital intubation it would lead a reasonable person to go, "Hmm...maybe there is a way we can achieve the same ends in patients (proper oxygenation, ventilation, etc) and not have the risks associated with field intubations....". I agree that there needs to be more research done, but I'm afraid given the increasingly retentive nature of IRBs towards human clinical research under implied consent it'll take a miracle (or some well placed bribes) to see it carried out at least in the US.

I don't dismiss Wang's study purely because it is retrospective. I dismiss it because it is retrospective; non-randomized; uses an unvalidated registry; relies on a functional impairment score that is not validated anywhere else in the literature; has no adustment made for various factors that could affect prehospital ETI (such as lack of RSI); does not account for failed attempts or why they occured (either in hospital or pre-hospital; does not provide any information on how or when in-hospital intubation was carried out; and does not use matching techniques; has no long term outcomes recorded.

It does nothing to build the case for or against prehospital intubation.

Oxygenation and ventilation may indeed be provided equally well in that subset of patient by BVM, but the real point is only that the type of massive brain injury that renders a person without airway reflexes also tends to kill them. I suspect if you ran that trial of ETI vs BVM in head-injured patients with absent airway reflexes you would not find much of a difference in outcomes. If, however you ran it in a service that has poor success rates and allows proling hypoxia followed by hyperventilation following ETI, then the suspicion would be that the outcomes would be worse still.

Which brings me to Davis.

The Davis (2003) study, whilst arguably having flaws in the study design (particularly with matching and scoring) at least added to our knowledge by starkly illuminating the importance of avoiding transient hypoxia and hyperventilation. This allows us to build on the study and move forward.

I believe the reasonable approach is to look at why we are failing to intubate in the first place and see if that can be corrected. I believe it can, and the numbers from my service demonstrate that medics can intubate as successfully as ED doctors given appropriate training, education and support. This then sets up the ideal conditions to be able to compare apples with apples so that we can work out whether or not it is important to be able to intubate in the field, and should also engender confidence in those whom we need to convince to allow us the free reign to carry out studies.

I am always game for more research, but I also see the other side of the issue that says why not use an easier option that delivers the same results with fewer risks? At very least until we settle the issue with more definitive research that would seem to be the more patient safety oriented thing to do.

I certainly undertand the point, however without a clear idea of how well the 'gold-standard' (and I use the term advisedly) performs, we are measuring with a flawed ruler. To compare the success of say LMA insertion with ETT insertion when we are only hitting the mark a handful of times with ETI does no justice to either technique. Failure to address the systemic issues in prehospital intubation does nothing but cloud the waters for further research. So far, the literature merely shows that ETI done poorly = poor outcomes.

It's just the way your previous post came across. Kind of like how you read my response to be hostile, I read yours as having the same attitude I've encountered numerous times in person from EMTs and paramedics whenever the issue of downplaying intubations comes up. For that you have my apologies.

Accepted, and you have mine also.

 

[Shishkabob]

Fine usaf, no allergic reaction. Still plenty if other times where intubation is needed over basic and rescue airways.


Laryngeal Edema caused by trauma.

Status asthmaticus refractory to all treatments and has horrible airway complience.


Or heck, someone with esaphogeal verices. You try a resue airway on them and you'll kill them.

 

[MCGLYNN_EMTP]

We arn't so much concerned with when is ETI prefered over basic rescue airways. What's the point of that if we can't even perform ETI successfully to being with? I think we need to find the cause of unsuccessful intubations and start from there. It's not that paramedics are just not capable of intubation in the pre-hospital setting, I believe not enough time is spent training on it. If paramedics are just flat out missing the intubation, we need more time training them on how to do it.

Also, who's to say that the reason the tube is not in place when the patient arrives to the ED is soley because the paramedic missed the intubation? Couldn't the paramedic have successfuly intubated the patient and then the tube become dislodged with movement of the patient? I also think if we spend a couple extra seconds after moving the patient to reassess breath sounds or watch your ETCO2 if available (or even both) then we can save alot of tubes from becoming dislodged in transfer of the patient.

When It comes down to it, The most important thing at the end of the day is did ETI really benifit my patient? Would PROPER USE of BVM and airway adjunct with sup O2 have done better? I agree Blind insertion devices such as King and Combitube just don't seem right because they require hardly any training to use, but in many instances they work just as good as an ETT.
I would really like to see what the future holds as far as airway managment goes.

 

[MCGLYNN_EMTP]

What other Airways do your services carry such as combi-tube?
we carry ETT NTT and Combi

 

[Shishkabob]

Who says anything about "preferred"?

In those 3 I posted, it's either an ETT or surgical/needle, and there is no reason to do a surgical airway if you can be just fine with an ETT.





I don't think anyone is fighting the "Use a BVM and OPA when it works" idea.





A blind insertion rescue airway can kill someone with esophageal verices.

 

[atropine]

Linuss it's just a stupid skill that not even proven to be effecteive, so who care if they take it away. I mean even in the new ACLS guides intubation is on the bottom of the totem pole and the AHA actually do the real science. Really it's not that big of a deal if the take it away.^_^

 

[Shishkabob]

Do you know WHY it's at the bottom for ACLS? Because often times a BVM + OPA can do the job, and they'd rather have blood pumping then an attempt at an ETT... but if you need an ETT, you need an ETT.

Now, look at PALS algorhythms. They want a more definitive airway asap, be it an OPA, King or ETT... whatever gets the job done, because pedi CA's are more airway related.



But you are missing the quite obvious point. Sure, intubation hasn't been 'proven' in cardiac arrest... but that's not the only emergency we deal with, and is not the only emergency that warrants / requires an ETT.

Cardiac arrest isn't all we do.

 

[atropine]

I get your point, but we don't run enough of those types of calls to do the ETT justice, I would like to see us and I think we are going to King airway which I personally think is way better than the ETT.^_^

 

[Shishkabob]

One saved life a month because of an ETT isn't justice enough?




The problem isn't proven / unproven ETT's. It's lazy and/or uneducated providers.

 

[atropine]

Wow what kind of sick people are there in texas, I guess everbody in souther Cali is healthy, cause man I haven't tubed in about 9 months.

 

[DrParasite]

here is a question from the uninformed:

why is a ETT considered the gold standard? meaning, can other procedures (such as an esophogeal tube) be used to prevent vomitting and gastic air (the exact term is eluding me at the moment), and an OPA and BVM can deliver air into the lungs. this could lead to less oral trauma FROM the ETT placement, as well as still deliver the oxygen to the patient.

I can still see an ETT being needed when dealing with airway burns, where there is a real threat of losing an airway.

but other than those cases where the airway is closing, why is the ETT considered the "gold standard"?

 

[Shishkabob]

Because OPA's and combi-tubes don't play friendly with ventilators, and if you have a pt with no arms, legs, or a sternum, you can push drugs down it. ^_^

 

[atropine]

Because OPA's and combi-tubes don't play friendly with ventilators, and if you have a pt with no arms, legs, or a sternum, you can push drugs down it. ^_^

Who pushes meds down the tube anymore

 

[MasterIntubator]

King airway which I personally think is way better than the ETT.^_^

Negatory big bird.... but I won't debate that with ya. The King/EOA/EGTOA/Combitube/LMA/etc are not direct airway devices. They work, and work well in the time of need. They get the job done, and as with intubation.... have their own set of problems. ( just uglier ).

The king.... its hard to plug the puke hole side vent. You get a bleed, or breech in the distal common cuff.... as with all the indirect tubes, and you will ventilate all the stuff into thier lungs. It happens... one of those ugly probs, you won't know it readily either.

Ya know.... if I am on the scene, and you got it in 2 seconds flat with confirmation... I would be the happiest puppy alive. ( pat on yer back ). I won't even mess with it.

 

[Crepitus]

Agreed, with a few reservations. However, I think we really should be less hostile to the idea of non-visualized airways with comparable functionality.

(quoted for the idea, not necessarily as a response to usafmedic who authored the quote)


usafmedic and smash have a great exchange going and I'm glad there are folks with their depth in the scientific side of the EMS pool. I'm nowhere near them, though I try every day to educate myself in some way or another. I do believe that anecdotal evidence derived from common place, practiced experience has value as well in the evaluation process. Thus I would like to share my experience and views on non visualized airways and get folks feedback as I'm open to the presented idea that ETT's are headed the way of the DoDo.

I started with EOA's and EGTA's as a back up to the ET. And they were stiff, holding the mask on never seemed as easy as it had been sold, relative to an ET tube the placement of the NG/OG wasn't as easy.

So those who were able placed an ETT.

But then we got the PTL's and that was going to be our salvation. So for a year or two we watched patients mouths deform under the pressure of the upper balloon because they never seemed to seal. And the tubes would creep up under the pressure. Of course the lower balloon sealed as well, so periodically a pt would puke past the lower balloon and the upper balloon held it all in guaranteeing an aspiration.

So those who were able placed an ETT.

Then some constant change/constant new idea guy ran out of the office to the field medics who were watching TV between calls (and BTW even though I find the constant change/constant new idea guy a PITA, we need him because relying on a TV watcher like me is going to get us in worse trouble) and showed us a CombiTube. The new salvation had arrived!

And I said - yeah so what. Somebody redesigned the PTL. No no CC/CNI guy replied this is something completely new! And so we spent a few years using an improved PTL with less complications while those of us who had learned (in the more complete sense of the word) to intubate just did that.

Recently as I prepared to return to EMS I watched paramedics at fairly busy ALS services tout the new thing, this time a King LT. I looked at it and said yeah so what. It's a one tube CombiTube.

No no this is different. How I ask? Well it's simpler they say.

My thoughts on that are well 'simpler that is faster' is indeed a good thing. If it's simpler because a paramedic found the CombiTube confusing . . . well I guess I don't want them intubating anyway.

But in the end, I don't personally find placing an ET complicated. I don't find that placing an ET tube takes me that long. About the same as CombiTube, probably longer than a King.

I agree that there is much more to airway management than tube placement. And I believe that I can say that while I have missed a tube, I have never missed an airway. I believe that while ventilation is our goal, good airway management resulting in a patent airway is the path to that goal.

-ETT is a more direct path to the goal. Because the blind airways take away my ability to see with my own eyes the patentcy of the airway it feels like a compromise. Because I give up the ability to place the air directly where I want it (trachea) and rely on a mechanical device (a balloon) to redirect the air it would seem that a diminished level of control of where that air is going is inevitable eventually.

-Relying on the same balloon to seal the gastric contents in (which typically are under pressure right ) rather than relying on a balloon in the trachea to seal against non pressurized secretions is counterintuitive. Particulary when you forfeit the NG/OG tube option. (though I understand the King LTS-D addresses this issue.)

-I am open to the idea of reprioritizing the pt care. If OPA/BVM needs to be done for a while while we redirect our emphasis, that seems reasonable. Maybe we'll scrap the whole ABC concept in CPR someday and do it CAB instead.

-While I have yet to become convinced that blind insertion airways have comprable functionality I believe that the blind inserts have a place. I've used them when I was unable to achieve a patent airway using an ET. I have seen other medics peform airway care with an ET that I would not accepted from myself and wish they had used a blind insert.

-Because I think that there will always be times when effective ETT intubation is inhibited by skill levels, environment, or the patient's condition I do believe that forcing all paramedics everywhere to always turn to the ET first is a compromise in pt care.

-But I think that forcing all paramedics everywhere 'down' to the use of a blind insertion airway first in every situation is a much more aggriegous compromise, because it seems to say 'okay, we give up, we won't ever be able to get these paramedics up to an acceptable level, so let's go ahead and lower the bar.'

Thanks to those of you read this long of a ramble and to the forum for the opportunity to exchange thoughts with all you.

Crepitus

 

[MasterIntubator]

Nice post, crep.

Nice.

 

[cfd3091]

Yes Crep, Very good.