Why are we placing ETTs at all?

[VentMonkey]

Forget the EMT/ paramedic assessment debate for a minute, but how many fresh out of school paramedics even look for, take into account, or are prepared for that difficult airway the second their eyes hit the patient?

Sure Mallampati scores may be brushed up on, perhaps Cormack scores too. They may touch on ramping a morbidly obese patient, but even with this how many will readily honestly say you know what the best I can do is effectively BVM, or let me just direct to SGA vs. knowing the proper patient for their skill abilities?

Hopefully schools are beginning to emphasize this methodology. Yes, ETT still has its place in the prehospital setting IMO, but the split second decisions most likely need to be much more accurate. And yes, without VL I don’t think any paramedic has any business attempting to intubate a predictably difficult airway.

 

[Tigger]

Forget the EMT/ paramedic assessment debate for a minute, but how many fresh out of school paramedics even look for, take into account, or are prepared for that difficult airway the second their eyes hit the patient?

Sure Mallampati scores may be brushed up on, perhaps Cormack scores too. They may touch on ramping a morbidly obese patient, but even with this how many will readily honestly say you know what the best I can do is effectively BVM, or let me just direct to SGA vs. knowing the proper patient for their skill abilities?

Hopefully schools are beginning to emphasize this methodology. Yes, ETT still has its place in the prehospital setting IMO, but the split second decisions most likely need to be much more accurate. And yes, without VL I don’t think any paramedic has any business attempting to intubate a predictably difficult airway.

We did have a condensed "difficult airway" day, but that was all about techniques once you had identified one. Additionally, we were required to assess 30 strangers airways, which consisted of a more targeted history, mouth opening, neck mobility, teeth presence, jaw protrusion, neck size, and Mallampati. Talk about some weird looks at the community college. Pretty useful exercise though. I think where things lacked the most though was sort of implying that everyone could be intubated. That's just not so for most paramedics, and knowing when difficult meant do not attempt was not something really touched on.

 

[Carlos Danger]

I'm not sure that assessing for the difficulty of an intubation should really be stressed to paramedics. This is largely because no assessments have ever been shown that reliable, but also because, as you often hear from the advocates of using rocuronium (vs. sux) for RSI, if a person really needs an airway established they need it, and the fact that it looks difficult doesn't take away that need. Between VL, SGA's, and cricothyrotomy, failed airways should be practically non-existent these days.

I'm not saying don't do an airway assessment, I'm saying don't focus a lot of effort on trying to predict the difficulty of intubation.

Just like we use universal precautions even on people who appear to be at low risk of having HIV or hepatitis, we should approach every intubation in the field as though we know it is going to be difficult. Make your first attempt your best attempt every time, and plan to move down your algorithm to cricothyrotomy. Having that deliberate mental preparation for moving down the algorithm is a useful cognitive "trick". Once you've gotten it in your head that you are likely going to have to do something like that, you've given yourself permission to take that step and it's a little easier to do, should it actually come to that.

I think the most important element of airway assessment in the field before doing an RSI is answering two questions:

1. Do I really need to take this airway? Right now? Is the benefit really worth the risk?
2. Can I easily identify the landmarks for cricothyrotomy? Not being able to should make you seriously consider the necessity of giving a paralytic.

 

[MackTheKnife]

It is interesting to note that the OP posted back in 2011 and the debate goes on still. The article cited by the OP came from PUBMED, a highly reliable source for EBP. However, in the article cited, it did not specify which locale, if any, or if it was a nationwide study. With the low sample population, I would think it would be relegated to a specific urban/suburban area vice nationwide.
I have engaged in debates on different forums about ET intubation, and some of the replies went to the lack of people surviving cardiac arrest neurologically intact who were intubated. I question the validity of this argument in that an ETT is not the sole arbiter of patient survival. Length of down time (anoxia), length of delay in ROSC, comorbidities, etc., all lead into whether or not the patient survives, neurologically intact or not.
Misplaced tubes should be a rarity, not commonplace. Yes, there the "no-neckers", people with anterior anatomy (my wife), etc. But if you can see the cords, you should be able to properly place the tube. I think some people rush their intubation and hope it's in the right place, IMHO.
I have also seen intensivists in the hospital pick too large a tube all too frequently. They are not a good judge of which size tube to use. They usually take at least two attempts to place the tube. And all use Macs. I prefer a Miller #3; I've always loved the straight blade.

 

[E tank]

I have also seen intensivists in the hospital pick too large a tube all too frequently. They are not a good judge of which size tube to use.

It isn't a question of poor judgement. Intensivists appreciate larger tubes in the event the patient requires ICU bronchoscopy and or lavage and by and large, respiratory therapists appreciate them for ease of routine pulmonary toilet, less likelihood of plugging etc.

 

[Carlos Danger]

It is interesting to note that the OP posted back in 2011 and the debate goes on still.

The debate started WAY before 2011, and it shows no signs of slowing down. After quite a few years of staying on top of the research related to EMS airway management and debating it ad nasueam, I have come to a few conclusions as to why the debate continues.

Suffice it to say that there is no other intervention that offers as much risk to the patient with as little demonstrated benefit - yet somehow continues to be considered "standard of care" - as prehospital endotracheal intubation.

The article cited by the OP came from PUBMED, a highly reliable source for EBP. However, in the article cited, it did not specify which locale, if any, or if it was a nationwide study. With the low sample population, I would think it would be relegated to a specific urban/suburban area vice nationwide.

PubMed indexes practically every article related to medicine that is published in journals written in English. So the quality and strength of the evidence presented in each article varies dramatically by study design and execution.

This study was done in Orlando over an eight month period in 1997. It is one of the rare prospective studies done in the US on prehospital intubation. With a sample size of 108, it's pretty legit in size, though you are correct in pointing out that it is limited to a single geographic location.

The reason for the high rates of unrecognized esophageal intubation in the study appears to be largely related to lack of use of Etc02 monitoring.

I have engaged in debates on different forums about ET intubation, and some of the replies went to the lack of people surviving cardiac arrest neurologically intact who were intubated. I question the validity of this argument in that an ETT is not the sole arbiter of patient survival. Length of down time (anoxia), length of delay in ROSC, comorbidities, etc., all lead into whether or not the patient survives, neurologically intact or not.

Well of course it isn't the sole arbiter but age, downtime, and co-morbidities are pretty easily controlled for in these studies. The investigators generally group the patients by those traits and run stats separately on each group. So that isn't really a problem. The evidence on how ETI affects survival from cardiac arrest is inconclusive. Some analyses show a benefit, some show that it doesn't help or even negatively correlates with survival. Personally I think we put too much emphasis on trying to bring back the dead so I tend not to pay a heck of a lot of attention to studies looking at different airway management techniques in cardiac arrest.

Where the rubber really meets the road is in looking at field RSI. There are a handful of retrospective studies on field RSI over the past 20 years and none of them have shown a clear benefit, while many have actually shown harm.

There has only been one large, well-done prospective study and that was the Bernard study done in Australia and was also very unconvincing.

Misplaced tubes should be a rarity, not commonplace.

Since Etc02 has become common in the field, misplaced tubes really don't happen that often. Most studies on field RSI show pretty high rates of success with tube placement. The problem as it relates to benefit appears not to be getting the tube, but all the other details.

 

[MackTheKnife]

It isn't a question of poor judgement. Intensivists appreciate larger tubes in the event the patient requires ICU bronchoscopy and or lavage and by and large, respiratory therapists appreciate them for ease of routine pulmonary toilet, less likelihood of plugging etc.

Yeah, but my point is they usually wind up downsizing!

 

[E tank]

[QUOTE"MackTheKnife, post: 663303, member: 10500"]Yeah, but my point is they usually wind up downsizing![/QUOTE]

I have also seen intensivists in the hospital pick too large a tube all too frequently.

Huh?