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Critical Care
Published in: Critical Care 1/2017

Open Access 01-12-2017 | Research

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis

Authors: K. Crewdson, D. J. Lockey, J. Røislien, H. M. Lossius, M. Rehn

Published in: Critical Care | Issue 1/2017

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Abstract

Background

Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates.

Methods

A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis.

Results

Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616–1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938–0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616–1.000) and, for physicians, were 0.988 (0.781–1.000) (p = 0.003).

Discussion

The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this intervention safely.
Literature
1.
Lockey DJ, Healey B, Crewdson K, Chalk G, Weaver AE, Davies GE. Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. 2015;114:657–62.CrossRefPubMed
2.
Jaber S, Amraoui J, Lefrant J-Y, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355–61.CrossRefPubMed
3.
Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008;34:1835–42.CrossRefPubMed
4.
Davis DP, Dunford JV, Poste JC, Ochs M, Holbrook T, Fortlage D, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma. 2004;57:1–10.CrossRefPubMed
5.
Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:202–22.CrossRefPubMed
6.
Lossius HM, Røislien J, Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care. 2012;16:R24.CrossRefPubMedPubMedCentral
7.
Hubble MW, Brown L, Wilfong DA, Hertelendy A, Benner RW, Richards ME. A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care. 2010;14:377–401.CrossRefPubMed
8.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group PRISMA. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535–5.CrossRefPubMedPubMedCentral
9.
10.
R Development Core Team. 2008. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. ISBN 3-900051-07-0, http://​www.​R-project.​org
11.
Lyon RM, Ferris JD, Young DM, McKeown DW, Oglesby AJ, Robertson C. Field intubation of cardiac arrest patients: a dying art? Emerg Med J. 2010;27:321–3.CrossRefPubMed
12.
Fullerton JN, Roberts KJ, Wyse M. Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK. Resuscitation. 2009;80:1342–5.CrossRefPubMed
13.
Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM. Out-of-hospital airway management in the United States. Resuscitation. 2011;82:378–85.CrossRefPubMed
14.
Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR. Paramedic training for proficient prehospital endotracheal intubation. Prehosp Emerg Med. 2010;14:103–8.CrossRef
15.
Diggs LA, Yusuf J-EW, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014;85:885–92.CrossRefPubMed
16.
17.
Wnent J, Franz R, Seewald S, Lefering R, Fischer M, Bohn A, et al. Difficult intubation and outcome after out-of-hospital cardiac arrest: a registry-based analysis. Scand J Trauma Resusc Emerg Med. 2015;23(43):1–9.
18.
Tam RK, Maloney J, Gaboury I, Verdon JM, Trickett J, Leduc SD, et al. Review of endotracheal intubations by Ottawa advanced care paramedics in Canada. Prehosp Emerg Care. 2009;13:311–5.CrossRefPubMed
19.
Denver Metro Airway Study Group. A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region. Prehosp Emerg Care. 2009;13:304–10.CrossRef
20.
Katzenell U, Lipsky AM, Abramovich A, Huberman D, Sergeev I, Deckel A, et al. Prehospital intubation success rates among Israel Defense Forces providers. J Trauma Acute Care Surg. 2013;75:S178–83.CrossRefPubMed
21.
Jacoby J, Heller M, Nicholas J, Patel N, Cesta M, Smith G, et al. Etomidate versus midazolam for out-of-hospital intubation: a prospective, randomized trial. Ann Emerg Med. 2006;47:525–30.CrossRefPubMed
22.
McQueen C, Crombie N, Hulme J, Cormack S, Hussain N, Ludwig F, et al. Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice. Emerg Med J. 2015;32:65–9.CrossRefPubMed
23.
Brown CA, Cox K, Hurwitz S, Walls RM. 4,871 Emergency airway encounters by air medical providers: a report of the Air Transport Emergency Airway Management (NEAR VI: “A-TEAM”) Project. West J Emerg Med. 2014;15:188–93.CrossRefPubMedPubMedCentral
24.
Cobas MA, La Peña De MA, Manning R, Candiotti K, Varon AJ. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg. 2009;109:489–93.CrossRefPubMed
25.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252:959–65.CrossRefPubMed
26.
Fakhry SM, Scanlon JM, Robinson L, Askari R, Watenpaugh RL, Fata P, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma. 2006;60:997–1001.CrossRefPubMed
27.
28.
Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, et al. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand. 2016;60:852–64.CrossRefPubMedPubMedCentral
29.
National Association of EMS Physicians. Drug-assisted intubation in the prehospital setting position statement of the National Association of Emergency Physicians. Prehosp Emerg Care. 2006;10:260.CrossRef
30.
Chesters A, Keefe N, Mauger J, Lockey D. Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J. 2014;31:65–8.CrossRefPubMed
31.
Soti A, Temesvari P, Hetzman L, Eross A, Petroczy A. Implementing new advanced airway management standards in the Hungarian physician staffed Helicopter Emergency Medical Service. Scand J Trauma Resusc Emerg Med. 2015;23:3.CrossRefPubMedPubMedCentral
32.
Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.CrossRefPubMed
33.
Cook TM, Woodall N, Frerk C, on behalf of the Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia. 2011;106:617–31.CrossRefPubMed
34.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103:33–9.CrossRefPubMed
35.
Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, et al. Airway management by physician-staffed Helicopter Emergency Medical Services—a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med. 2015;23:57 1–10.CrossRef
36.
Lockey D, Davies G, Coats T. Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study. BMJ. 2001;323:141.CrossRefPubMedPubMedCentral
37.
Sollid SJM, Lockey D, Lossius HM. Pre-hospital advanced airway management expert group. A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. Scand J Trauma Resusc Emerg Med. 2009;17:58.CrossRefPubMedPubMedCentral
38.
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–48.CrossRefPubMedPubMedCentral
39.
Breckwoldt J, Klemstein S, Brunne B, et al. Expertise in prehospital endotracheal intubation by emergency medicine physicians—comparing ‘proficient performers’ and ‘experts’. Resuscitation. 2012;83:434–9.CrossRefPubMed
40.
Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86(3):635–9.CrossRefPubMed
41.
Lockey DJ, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth. 2014;113(2):220–5.CrossRefPubMed
42.
Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann H-C, Arntz H-R. Difficult prehospital endotracheal intubation—predisposing factors in a physician based EMS. Resuscitation. 2011;82:1519–24.CrossRefPubMed
43.
Fullerton JN, Roberts KJ, Wyse M. Should non-anaesthetists perform pre-hospital rapid sequence induction? An observational study. Emerg Med J. 2011;28:428–3.CrossRefPubMed
44.
Germann CA, Baumann MR, Kendall KM, Strout TD, Mcgraw K. Performance of endotracheal intubation and rescue techniques by emergency services personnel in an air medical service. Prehosp Emerg Care. 2009;13:44–9.CrossRefPubMed
45.
von Vopelius-Feldt J, Benger JR. Prehospital anaesthesia by a physician and paramedic critical care team in southwest England. Eur J Emerg Med. 2013;20:382–6.CrossRef
46.
Le Cong M. Flying doctor emergency airway registry: a 3-year, prospective, observational study of endotracheal intubation by the Queensland section of the Royal Flying Doctor Service of Australia. Emerg Med J. 2012;29:249–50.CrossRefPubMed
47.
Kamiutsuri K, Okutani R, Kozawa S. Analysis of prehospital endotracheal intubation performed by emergency physicians: retrospective survey of a single emergency medical center in Japan. J Anesth. 2012;27:374–9.CrossRefPubMed
48.
Rognås L, Hansen TM, Kirkegaard H, Tonnesen ET. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013;21:58.CrossRefPubMedPubMedCentral
49.
Lah K, Krizmaric M, Grmec S. Rapid sequence intubation in the pre-hospital setting–difference between trauma and nontrauma patients. Signa Vitae. 2010;5(1):34–9.
50.
Merlin MA, Safdar H, Calabrese S, et al. Prehospital rapid sequence intubation in an emergency medical services system with two advanced life support providers. Prehosp Disaster Med. 2010;25:341–5.CrossRefPubMed
51.
Caruana E, Duchateau F-X, Cornaglia C, Devaud M-L, Pirracchio R. Tracheal intubation related complications in the prehospital setting. Emerg Med J. 2015;0:1–6.
52.
Sollid SJ, Lossius HM, Søreide E. Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med. 2010;18:30.CrossRefPubMedPubMedCentral
53.
Thoeni N, Piegeler T, Brueesch M, et al. Incidence of difficult airway situations during prehospital airway management by emergency physicians—a retrospective analysis of 692 consecutive patients. Resuscitation. 2015;90:42–5.CrossRefPubMed
54.
Gunning M, O'Loughlin E, Fletcher M, et al. Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service. Emerg Med J. 2009;26:65–9.CrossRefPubMed
55.
Gunning M, Perkins Z, Crilly J, et al. Paramedic rapid sequence induction (RSI) in a South African emergency medical service: a retrospective observational study. S Afr Med J. 2013;103(9):632–7.CrossRefPubMed
56.
Helm M, Kremers G, Lampl L, et al. Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists. Acta Anaesthesiol Scand. 2013;57:199–205.CrossRefPubMed
57.
Timmermann A, Russo SG, Eich C, et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg. 2007;104(3):619–23.CrossRefPubMed
58.
McIntosh S, Swanson ER, McKeone AF, et al. Location of airway management in air medical transport. Prehosp Emerg Care. 2008;12(4):438–42.CrossRefPubMed
59.
Vadeboncoeur TF, Davis DP, Ochs M, et al. The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation. J Emerg Med. 2006;30(2):131–6.CrossRefPubMed
60.
Bernard SA, Smith K, Porter R, Jones C, Gailey A, Cresswell B, et al. Paramedic rapid sequence intubation in patients with non-traumatic coma. Emerg Med J Emerg Med J. 2015;32:60–4.CrossRefPubMed
Metadata
Title
The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis
Authors
K. Crewdson
D. J. Lockey
J. Røislien
H. M. Lossius
M. Rehn
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2017
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1603-7

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