American airway management in the field

I often wonder why my US colleagues are so vehemently opposed to out-of-hospital tracheal intubation. This paper provides a clue. I would love it if any EMS providers out there could comment, as I find these results staggering.

The authors comment that the data set “contains data on over 4.3 million EMS events from 16 states (Alabama, Colorado, Florida, Hawaii, Iowa, Maine, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, and Oklahoma) for the one-year period January 1, 2008–December 31, 2008. These states were the first to participate in the NEMSIS project. There are no estimates of the numbers of EMS agencies or EMS responses that are not included in NEMSIS. Hawaii, New Jersey, New Mexico and Oklahoma provided only partial data for the study period because of their implementation of NEMSIS during 2008.

OBJECTIVE: Prior studies describe airway management by single EMS agencies, regions or states. We sought to characterize out-of-hospital airway management interventions, outcomes and complications across the United States.


METHODS: Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiac arrest, non-arrest medical, non-arrest injury, children <10 and 10-19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics.

RESULTS: Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1-77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10-19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).

CONCLUSIONS: In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.

Out-of-hospital airway management in the United States
Resuscitation. 2011 Apr;82(4):378-85

8 thoughts on “American airway management in the field”

  1. Coming from an EMT in the US, this is a huge study, both in size and implications. I would love to get my hands on the full paper, but at a glance most of this data matches what I would expect. That isn’t to say I like the numbers I’m seeing, but they do pass the plausibility test. I’d expect sedation-only laryngoscopy to provide less than ideal intubating conditions, and considering the difficulties inherent in the prehospital environment, rates in the 75% range are not something to be proud of, but aren’t a surprise to me. What has me shocked is the EXTREMELY low rate of successful RSI attempts. Now I don’t have any idea about the true veracity of the data, but an 81.4% success rate when you’re paralyzing someone is embarrassing. Either training has to increase dramatically or I suspect many regions will be doing away with ETI for their medics. More likely the latter… {shakes head}

  2. Just for some added context, I’d expect sedation only rates in the 80’s, RSI around 95% or greater, and alternative airway success at 90-95% depending on what’s used and in what situation. Seeing as only one of those predictions, alternative airways, came close to the study results, I think we have a good answer as to where the future of prehospital airway management will be heading.

  3. Sarcastic? We suck at it. As a paramedic in the south east I can attest to the severe lack of education and training that comes with the territory of being a prehospital provider here. We are not against it just not good at it. With time comes understanding. With understanding comes change. We take a long time to learn.

  4. Cliff,

    Intubation education for prehospital providers is pretty bad. Couple that with little practical experience in school, and a few attempts per year, you’ll find we don’t get a good chance to maintain the skill. Why do you think I came to the airway class in Baltimore?

    I’m a bit skeptical of the alternate airway numbers, as it may include devices that just plain suck (e.g. combitube). The number of unrecognized esophageal intubations is lower than in other studies, but likely due to the addition of capnography in many areas. In NC, where I practice, it is required on all prehospital intubations.

    The only way to fix this problem is to fix our education and begin limiting the skill to providers who maintain and prove competency. OR access may help, it may not as well.

    Some things I picked up from you guys during our talks was the near universal use of bougies. I’m working on making this happen at my own service, but I can tell you in my general area they are rare to find.

    Regardless of what happens, we’re collecting the data, we have numbers. We should put a plan in place to improve.

  5. After reading the full text of the paper (thanks Christopher), a couple of points jumped out at me. Although the overall alternative airway success rate was lower than desired thanks to the Combitube and EOA, the LMA proved very useful with 95% success and a usable n-value. Second, although the number of unrecognized esophageal intubations was low, as we would hope, the rate of recognized esophageal tubes was much lower than I’ve encountered both in the field and in the emergency department setting, casting doubt on the validity of both self-reported complication rates.

    If they could have included one more subset of data, I would love to have seen the results broken down between needle-crics and open methods. Although the numbers were not large, I’m still very interested in what they would have shown in light of your recent examination of the NAP4 data with Dr. Weingart.

  6. I have to agree with what has already been said. Pre-hospital airway management is an area that requires a great deal of improvement.

    When I went through school we were required to have a minimum of 5 successful intubations in the OR. It was a bonus if we were able to do so in the field while doing our clinical rides. I have been told by some students in the various places that I have worked that they do not even do any OR time to practice airway management now. It is all done on a mannequin. They are great for learning the basics, but I feel that really doesn’t cut it. Instrumenting a real human airway is totally different from intubating “Ed the Head” in a class room. just my opinion here, but I don’t think that adequately prepares students to become adequate pre-hospital providers. Many of our newer medics (less than 2 years on the job) have never successfully placed an ET tube. I found that to be very surprising.

    At any rate, ET intubation is something that will be debated here in the US for a long time to come. But from my seat in the truck, airway management education and training needs an overhaul.

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