The Disappearing Endotracheal Tube

[VentMedic]

I just attended our monthly continuing education last night and I got the impression that the service is working towards eventually eliminating endotracheal intubation. The most notable change is our new cardiac arrest guidelines where first responders (EMTs) will be putting in the LMA and “managing” the airway while paramedics initiate vascular access and focus on ACLS and induced hypothermia should the patient meet the criteria. This is one of the first steps that I see them taking to weed out field intubations. Aside from that though, since this does appear to be around the corner for some providers, what will be the best means of managing the airway without endotracheal intubation?

I would not be in favor of using an LMA with a hypothermia protocol since paralytics are usually part of it.

You should have a secure airway (ETT) established and verified before any paralytics are used in the field.

Edited March 26, 2009 by VentMedic

[FL_Medic]

I would not be in favor of using an LMA with a hypothermia protocol since paralytics are usually part of it.

You should have a secure airway (ETT) established and verified before any paralytics are used in the field.

what would be the point of the paralytics if you have the ETT already?

[VentMedic]

what would be the point of the paralytics if you have the ETT already?

If the patient shivers, you defeat the purpose of the hypothermia by having the body work to raise the body's temperature.

Edited March 26, 2009 by VentMedic

[FL_Medic]

If the patient shivers, you defeat the purpose of the hypothermia by having the body work to raise the body heat.

Disregard, I should have read to see that this was in the context of a post-arrest hypothermia treatment. You are correct, although our guideline will not include a non-depolarizing paralytic. For some reason, we have had an in-service training and are about to launch this protocol in our system without the use of Vec/Roc. I attended a conference by Brent Myers a couple years ago and can't wait to see what kind of outcomes we get.

[VentMedic]

launch this protocol in our system without the use of Vec/Roc.

Any reason for this not to be included?

Does your service do RSI? Are you able to do paralytics for maintenance?

Edited March 26, 2009 by VentMedic

[FL_Medic]

Any reason for this not to be included?

Does your service do RSI? Are you able to do paralytics for maintenance?

We RSI, Etomidate, Succs, Diprivan (Fentanyl is optional). Don't know the reason, we aren't even going to titrate the temp, just 2 liters of cold saline after ROSC.

Edited March 26, 2009 by FL_Medic

[ncmedic309]

We don't have the option to RSI, we are using Diazepam to combat the shivering during the induced hypothermia. On another note, I'm not a fan of the LMA period - it's just not that great of a device for EMS providers to be using to "control" the airway. I fail to see the hypothermic protocol improving survival and neurological function when we can't even effectively manage the airway.

[kristo]

A recent Canadian study comes to mind, regarding the complications of intubation of the critically ill. The researchers' theory was that the risk of complications in this patient population would be significantly larger than in the usual pre-planned operations in the OR.

Here's their introduction:

In the operating room, endotracheal intubation (ETI) is generally performed on fasted, optimized patients, by anesthesiologists who are expert in airway management. As such, severe complications are rare [1]. In contrast, critically ill patients are typically unstable with poor physiologic reserve. There may be limited, if any, time for optimization [2]. Furthermore, ETI is often being performed in chaotic environments, with basic equipment, by individuals with varying airway management expertise. Many of the medications used to facilitate ETI have adverse hemodynamic consequences [3]. This may limit, if not preclude, their use in the critically ill. Finally, the risk of difficult intubation is high, ranging between 8 and 22% [4, 5].

As such, it is not surprising that the few studies on ETI in the critically ill demonstrate a risk of complications as high as 54% [6]. Even in intensive care units (ICU’s) where the majority of intubations are performed by individuals with anesthesiology training, severe life-threatening complications have been reported at 28% [7]. Schwartz et al. [4] observed an esophageal intubation in 8%, aspiration in 4% and mortality within 30 min of intubation of 3%. However, the relationship between expertise level of the intubating physician and risk of complications remains unclear. Thus, the goals of our study were twofold. First, we wanted to characterize the risk of complications related to ETI in a Canadian academic ICU, where the primary intubating physicians, although supervised, have varying airway management skills and experience. Second, we wanted to determine the risk of complications, ICU and hospital mortality, comparing expert to non-expert primary intubating physicians.

Their results were, at least to me, stunning:

Overall risk of complications was 39%, including: severe hypoxemia (19.1%), severe hypotension (9.6%), esophageal intubation (7.4%) and frank aspiration (5.9%).

Please keep in mind, this is for intubations done inside the hospital, in an ICU, by a mixed population of expert anesthesiologists and non-expert physicians, supervised by the former.

There are also other studies with similar results. I strongly believe this is something to think about when we choose airway management techniques for use in the field.

The study: Griesdale DEG, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. INTENSIVE CARE MEDICINE Volume: 34 Issue: 10 Pages: 1835-1842 Published: OCT 2008.

Link on Web of Science: http://apps.isiknowledge.com/full_record.d...omRightClick=no

Full text (may need subscription): http://www.springerlink.com/content/c57827...8/fulltext.html