Why are we placing ETTs at all?

[usalsfyre]

I haven't gotten a hold of the full article yet, but when stuff like this comes out, I really have to ask, why are we even attempting ETTs when we have good, reliable supraglotic airways?

A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotracheal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords.

Bolding mine

 

[Afflixion]

This is a good question, one common answer is that the ETT the best way to secure an airway. The rebuttal to that is the airway is not very well secured with the ETT in the esophagus. From what I've been reading here is that a lot of countries who have advanced EMS do not use ETTs rather they use LMAs and King LTs for the mot part. Even a large majority of anesthesiologists are using LMAs for short surgeries, as they place considerably less stress on the body and the vagal response is minimal compared to ETTs.

 

[Shishkabob]

The problem isn't necessarily missed intubations, it's unnoticed missed intubations, which with things such as wave-form capnography, and, I don't know, actually doing a good assessment, it should be a thing of the past.

But, at the same time, I have to question how many were missed, and how many migrated during movement?

 

[abckidsmom]

Should be and IS are so very, very different. I spent some time reading the Wake County protocols this morning, and even though there were lots of accountability procedures built into the protocol, I have a hard time believing that everyone in the system is on that level of performance.

In my experience, it's the majority of medics out there who just do whatever they want and blame the urgent nature of the job or any random thing for their failure to follow specific patient-safety-inspired guidelines.

I have NEVER seen an unrecognized misplaced ETT in a hospital. I have seen many misplaced tubes that were always noticed and corrected immediately. It's the lack of accountability and freelancing behavior.

 

[WTEngel]

I would be interested in knowing the statistical breakdown by specific service too. If the breakdown of missed intubation by individual EMS service proved to be fairly uniform according to number of intubation attempts, then yes, you could say there is a larger issue. However, if the breakdown indicates that of the missed intubations, 80% were from one particular service, and the other 20% were distributed over the other services, then it isolates the issue a little more.

Intubation is a great tool for field personnel to use. Like all tools, it is one that needs to be used at the appropriate time, with appropriate technique, etc. In my mind the issue of missed intubations can be looked at in the larger context of how many of those patients actually needed intubation? If we are intubating patients who could be treated otherwise, then we are taking a huge risk without much benefit, which is a much worse problem in my opinion.

The bottom line is that it comes down to individual accountability. The individual paramedics are responsible for having the knowledge skills and abilities to be able to get intubations with 100% success rate (not necessarily first attempt.) Showing up with a misplaced tube is absolutely reprehensible. Medical directors need to be individually accountable also. If they are not providing the oversight and education, then the problem is just as much their fault as it is the individual provider. They have essentially created "cowboys" who intubate first, and ask questions later.

Too many providers look at intubation as a procedure without consequences. Even with perfect initial placement, the rate of complications suffered from filed ET tube placement is something that should be taken into consideration when making the decision to intubate. Like all things it should be weighed against the other risks, and factored into the benefit expected to be gained...and all this should happen in a matter of 2-3 seconds for the seasoned provider, right?

 

[usalsfyre]

The problem isn't necessarily missed intubations, it's unnoticed missed intubations, which with things such as wave-form capnography, and, I don't know, actually doing a good assessment, it should be a thing of the past.

As abc notes, should be. Apparently by reading the blog post on this at Rogue Medic waveform capnography was available but not consistently used in this system. I've also seen medic argue that the capnography was "wrong" :blink: because they heard "breath sounds" that were actually transmitted from the abdomen.

But, at the same time, I have to question how many were missed, and how many migrated during movement?

It's a legit question as far as identifying where the problem is, but in the end really doesn't matter. If we can't manage ETTs after correctly placing them we still don't need to be placing them. Anecdotaly I have a feeling that assuming a commercial holder and cuffed tube, the device is applied directly and it and the tube are reasonably dry and you disconnect the BVM for moves it would be difficult to displace the tube unless your moving the patient by the ETT.

 

[usalsfyre]

In my experience, it's the majority of medics out there who just do whatever they want and blame the urgent nature of the job or any random thing for their failure to follow specific patient-safety-inspired guidelines.

I see this more and more (I'm sure it has always gone on, I'm just becoming more aware of it). And it pisses me off more and more each time. EMS has got to stop living in a "public safety not medicine cocoon". If an anesthetists did this we would consider it manslaughter.

I have NEVER seen an unrecognized misplaced ETT in a hospital. I have seen many misplaced tubes that were always noticed and corrected immediately. It's the lack of accountability and freelancing behavior.

Tubes will be misplaced and displaced. It happens. The recognition and response is the difference.

 

[ChorusD]

I really have to ask, why are we even attempting ETTs when we have good, reliable supraglotic airways?


Bolding mine

LMAs and King LTs are really nice, especially in patients who have been fasting for 24 hrs. However, how many burn patients or cardiac arrests have you worked with patients that have no gastric contents?

The truth is that the ETT is the gold standard in airway protection for a reason. Beyond that, it is definitely the paramedic's responsibility to ensure the tube is in place after placement and after pt movement and twice before turning over care to the ER.

my .02

 

[usalsfyre]

I would be interested in knowing the statistical breakdown by specific service too. If the breakdown of missed intubation by individual EMS service proved to be fairly uniform according to number of intubation attempts, then yes, you could say there is a larger issue. However, if the breakdown indicates that of the missed intubations, 80% were from one particular service, and the other 20% were distributed over the other services, then it isolates the issue a little more.

The the study even notes more data is needed to determine how wide spread the issue is. I'm working on getting a copy of the full study now.

Intubation is a great tool for field personnel to use. Like all tools, it is one that needs to be used at the appropriate time, with appropriate technique, etc.

Based on our discussions on here, I hope you realize we agree 100%

In my mind the issue of missed intubations can be looked at in the larger context of how many of those patients actually needed intubation? If we are intubating patients who could be treated otherwise, then we are taking a huge risk without much benefit, which is a much worse problem in my opinion.

Probably a bigger and more pervasive problem, but it's not out and out killing patients. What's presented above is.

The bottom line is that it comes down to individual accountability. The individual paramedics are responsible for having the knowledge skills and abilities to be able to get intubations with 100% success rate (not necessarily first attempt.) Showing up with a misplaced tube is absolutely reprehensible. Medical directors need to be individually accountable also. If they are not providing the oversight and education, then the problem is just as much their fault as it is the individual provider. They have essentially created "cowboys" who intubate first, and ask questions later.

Unfortunately, EMS hasn't really shown themselves to be up to the task. What I've seen is vehemently defending intubation without much real reason other that "we've always done it" and ego ("nurses can't do this!"). Anyone who shows up with a dead patient that has misplaced tube and doesn't recognize it, with the modern technology commonly available, is guilty of involuntary manslaughter in my mind.

Too many providers look at intubation as a procedure without consequences. Even with perfect initial placement, the rate of complications suffered from filed ET tube placement is something that should be taken into consideration when making the decision to intubate. Like all things it should be weighed against the other risks, and factored into the benefit expected to be gained...and all this should happen in a matter of 2-3 seconds for the seasoned provider, right?

The problem is we don't have experienced providers doing it, and a lot of "experienced" providers don't know the complications because their exposure to medicine ends at the ED doors.

I'm an advocate for paramedic advancement. However, sitting here, looking at this, along with a few things I've personally witnessed in the last year and a half, I can't say I would allow your average paramedic to intubate (no, not just RSI, placing ETTs period) if I was writing protocols. A subset of experienced medics with a good bit of additional education and strong oversight, sure. Joe Blow because he has a pulse and managed to "homeostase"(thanks Brown) his way through a medic program? No way in hell. The LMA and King LTs simply do too good of securing an airway. The fact that I'm starting to think this way scare the crap out of me, because where do we go from here?

 

[usalsfyre]

LMAs and King LTs are really nice, especially in patients who have been fasting for 24 hrs. However, how many burn patients or cardiac arrests have you worked with patients that have no gastric contents?

This is the kinda crap I'm talking about when we defend intubation. As Afflixion noted, how secure is an airway with the tube in the goose?

The truth is that the ETT is the gold standard in airway protection for a reason.

Who decided an ETT was the "gold standard"? What are the aspiration rates with LMA and King LTs in the non-NPO patient? What about rates with the variants of each that allow you to place gastric tubes? Do we even know? If your not placing OGs the benefit of having the "gold standard" is not nearly what you think.

Beyond that, it is definitely the paramedic's responsibility to ensure the tube is in place after placement and after pt movement and twice before turning over care to the ER.

What are the consequences in most systems for not doing this? For not using continuous waveform capnography? Like I said, Paramedics and EMS as a whole haven't shown to be up to the task.

 

[boingo]

Is this a recent article? There was a study published in Annals of Emergency Medicine 10 or 15 yrs ago that had somewhere around a 25% misplaced ETT rate, was out of Orlando, Florida.

I can't imagine there is a medical director out there who would allow this to occur.

 

[8jimi8]

Which device is safer for the pt?

Can you think of any situations in which ETI is indicated while other devices are not?

At least this is a lesson I will not learn the hard way.

 

[boingo]

Which device is safer for the pt?

Can you think of any situations in which ETI is indicated while other devices are not?

At least this is a lesson I will not learn the hard way.

Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.

 

[ChorusD]

This is the kinda crap I'm talking about when we defend intubation. As Afflixion noted, how secure is an airway with the tube in the goose?
Okay I agree with the fact that the airway is not protected if the tube is in the esophagus.

Who decided an ETT was the "gold standard"? What are the aspiration rates with LMA and King LTs in the non-NPO patient? What about rates with the variants of each that allow you to place gastric tubes? Do we even know? If your not placing OGs the benefit of having the "gold standard" is not nearly what you think.

I'd say the people who decided it was the "gold standard" are a group of people with a much more considerable amount of training, education, and experience than MOST, not all, of us here.

Do you mean the aspiration rates of an LMA when it's placed in patients with no contraindications? Those contraindications, from what I have read, include patients who are not NPO.


What are the consequences in most systems for not doing this? For not using continuous waveform capnography? Like I said, Paramedics and EMS as a whole haven't shown to be up to the task.

If it's better for our patients then I'm all for it. But, I don't believe that there will never be a time when a patient needs an ETT. Like a burn pt or any other pt with laryngeal edema refractory to medication.

Sure, put the King LTs and LMAs on the trucks but don't remove the ETT.

Oh and just to be sure, I don't call your point of view crap so I would appreciate it if you would show me and others the same courtesy. I'm willing to admit if I am wrong, my main purpose for reading this board is to learn not to try to prove you wrong. The "rebuttals" I post aren't to that point, rather it's to further explore a topic and therefore learn more about it.

 

[jrm818]

Is this a recent article? There was a study published in Annals of Emergency Medicine 10 or 15 yrs ago that had somewhere around a 25% misplaced ETT rate, was out of Orlando, Florida.

I can't imagine there is a medical director out there who would allow this to occur.

This is that study.

I can't disagree with much of the discussion thus far, but really this study is lacking in a lot of ways. If you manage to get the full text (PM me if you're can't get it easily) you'll see that really you don't get much more information than the abstract.

It's unclear how much colormetric versus waveform capnography was used, though it sounds like mostly colormetric. The misses aren't really well characterized, except that they seem to have been detected by direct laryngoscopy (and I wonder how good of a "gold standard" this is). It's not totally clear to me if it was residents or attending performing the laryngoscopy, and given that the authors started with a predisposed suspicion of high miss rates, I wonder about the risk of investigator bias in evaluating placement.

Similarly, and I see that rogue mentions this, tube dislodgement is possible during the final move from stretcher to hospital bed, and its not valid to attribute that to EMS error, when the EMS providers have no chance to re-evaluate placement prior to physician evaluation of the tube. I also wonder if there is a chance of dislodgment during the manipulation that I"m sure occured to facilitate direct laryngoscopy for verification.

All that aside, I think we're left with a good chance that in this system there is actually pretty poor performance with ETI, but with a study that is far from definitive, and the generalizability of the results are certianly in question. Actually a recent paper by Dr. Wang suggests that more current missed esophageal intubations occur at a miniscule rate: 1/1000 (the effect of waveform capnogrphy perhaps? Or maybe a methodological error?).
http://www.ncbi.nlm.nih.gov/pubmed/21288624

Of course this Wang paper is retrospective from a national database, and so there are all sorts of potential errors, biases, etc.

As with much of Dr.Wang's papers, really it seems like the message from the Florida paper is that there are many systems in the US with poor performance with ETI. That is no the same as saying that ETI should not be used in the prehospital setting, instead its a call to optimize your system's performance.

What drives me nuts is that there are many authors who are concerned with prehospital ETI and spend much time and effort performing multiple retrospective studies which seem to imply a problem, yet we have to look to the other side of the world to get a prospective study of prehospital intubation. I don't think that we even have a clear picture of the effectiveness of supraglottic airways versus ETI in a non-NPO field patient, and that seems to be a signifigant deficit in our knowledge.

It seems to me that what is needed is a prospective randomized trial in a high performing system of ETI versus supraglottic versus BVM prehospitally. I suppose that may be a pipe dream, but there is so much time and energy going into sub-optimal studies that I wish we could skip a few and combine the focus into a high quality study.

 

[usalsfyre]

I'd say the people who decided it was the "gold standard" are a group of people with a much more considerable amount of training, education, and experience than MOST, not all, of us here.

But WHO were they, and more importantly WHEN was this decided? Is it time to revisit this topic? Because I've heard "gold standard" parroted by every paramedic I've known for 10 years now, with very little understanding of what that means.

Do you mean the aspiration rates of an LMA when it's placed in patients with no contraindications? Those contraindications, from what I have read, include patients who are not NPO.

Fair, but your talking about contraindications used in the anesthesia setting, not for emergency airway control.

If it's better for our patients then I'm all for it. But, I don't believe that there will never be a time when a patient needs an ETT. Like a burn pt or any other pt with laryngeal edema refractory to medication.

Certainly agree with you there. However, is the number of these patients greater than the number of patients who are killed/have a more complicated clinical course by missplaced and inappropriate ETTs? Because we have to focus somewhat on what's better for the patients as a whole.

Sure, put the King LTs and LMAs on the trucks but don't remove the ETT.

If it can't be done effectively and well by paramedics, why are we putting patients at risk of a half-@ssed provider mucking it up?

Oh and just to be sure, I don't call your point of view crap so I would appreciate it if you would show me and others the same courtesy. I'm willing to admit if I am wrong, my main purpose for reading this board is to learn not to try to prove you wrong. The "rebuttals" I post aren't to that point, rather it's to further explore a topic and therefore learn more about it.

I'm sorry if this offended you. I'm not saying your full of crap. Looking at your info, it appears your a student, so I have a feeling you're repeating what's been taught to you so far in your career. The honest truth is many EMS providers arguments for or against a particular issue ARE crap. There full of anecdotes, logical fallacies and tradition. If more people are being harmed by endotracheal intubation than helped by it it needs to be pulled. Keeping it on the truck "just in case" means that skill will likely be so degraded by the time you need to use it it will be worthless anyway. There were probably people helped by blood letting and lobotomies too. However, the harm far outweighed the good.

 

[usalsfyre]

My bad on citing an old study. The new question is, have we improved enough in the ensuing 10 years that this is a non-issue? My personal feeling is no, but I'd like to see what y'all think.

 

[abckidsmom]

My bad on citing an old study. The new question is, have we improved enough in the ensuing 10 years that this is a non-issue? My personal feeling is no, but I'd like to see what y'all think.

In the systems I see (1 busy urban system 3rd service system, 1 busy suburban fire-based system, and 1 rural, combination career/volunteer fire-based system) there is improvement from 10 years ago, but I think that primarily comes from backup airways. People are not hesitant to pull the tube and drop a King.

Like you, I would like to see a study about whether the alternative airways really "count" and make any improvement in patient outcomes.

 

[8jimi8]

Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.

Then we cannot take away ETI.

 

[MrBrown]

Barely homeotasasing looser cookbook medics perhaps?