New JAMA article on Airway mgmt in OHCA

[turkeyjerky]

Anyone see/have thoughts on this new article?

Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Basically the jist is that both Endotracheal intubation and Extraglottic airways were associated w/ significantly reduced rates of neurologically favorable or intact survival as compared to BVM ventilation. I haven't read the article that closely yet, and I'm sure there are tons of confounders making it difficult to draw conclusions, but it's surprising to me that BVM beat out SGA's in addition to ETTs. Thoughts?

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[docB]

We're amassing a lot of data that seem to show that doing anything other than compressions reduces survival. We may soon get to a point where we do compressions until we get an organized complex or a shockable rhythm and postpone everything until after that.

 

[BB8730]

Very interesting - thanks for sharing.

For those of you with more experience in EMS - after a major study like this finds something contradictory to current EMS dogma, how long does it usually take until we see a change in EMS practice/protocols?

 

[Dwindlin]

Very interesting - thanks for sharing.

For those of you with more experience in EMS - after a major study like this finds something contradictory to current EMS dogma, how long does it usually take until we see a change in EMS practice/protocols?

Years. If ever. Look at back-boards.

 

[alpinism]

Yup, many, many years. Plus there needs to be replication(s) of the study and meta-analyses performed etc... before it should ever be considered for incorporation into practice.

Its becoming more and more clear that doing anything (incl. intubation) that interrupts compressions/defibrillation reduces survival in OHCA.

Compressions + hypothermia, then shock if able.

 

[leviathan]

It may also have to do with the fact that either ETTs or supraglottic airways = better ventilation = they end up getting hyperventilated which we know is bad for outcomes.

 

[docB]

It may also have to do with the fact that either ETTs or supraglottic airways = better ventilation = they end up getting hyperventilated which we know is bad for outcomes.

Now there's a study. Current vs. fewer resps (e.g. 4/min) vs. no ventilation.

I think there's also a need for data on using lower O2 content such as RA. There is a lot of evidence that 100% O2 causes ozone/free radicle related lung damage. The question has been if this is offset by the tissue oxygen delivery increase of 100%. Hard to say and hard to study.

I know there is some passive ventilation that happens due to gas movement with compressions. This is primarily dead space ventilation but the thought is that the small amount of actual ventilation may be what makes compression only resus feasible. There are those who advocate doing compressions only with an NRB in place for single rescuer codes. This may be the way we go in general.

 

[joeDO2]

I know there is some passive ventilation that happens due to gas movement with compressions. This is primarily dead space ventilation but the thought is that the small amount of actual ventilation may be what makes compression only resus feasible. There are those who advocate doing compressions only with an NRB in place for single rescuer codes. This may be the way we go in general.

Yes, I think the data so far would support compressions only with NRB. In most cases adequate saturation is maintained for at least 8 minutes. At that point however I think we need to start thinking about dealing with ventilation. Whether this is done with ETT or not is up for debate. Personally I feel supraglottic is the way to go. I guess the problem with this is that ETT skills would diminish even further and there is evidence that it is beneficial in other situations outside of arrest.

 

[alpinism]

Yes, I think the data so far would support compressions only with NRB. In most cases adequate saturation is maintained for at least 8 minutes. At that point however I think we need to start thinking about dealing with ventilation. Whether this is done with ETT or not is up for debate. Personally I feel supraglottic is the way to go. I guess the problem with this is that ETT skills would diminish even further and there is evidence that it is beneficial in other situations outside of arrest.

Its funny, in the accompanying editorial they mentioned that in Pennsylvania, medics perform a median of 1 ET intubation per year, which tbh was surprising to me.

I dunno about you guys, but even at the slowest stations I've ever worked we would do at least 1 every other month (prob 6-10 per year). Although, it might just be different state/jurisdictional protocols and they prob also included part-time medics as well as those only working in EDs (plus its the median not the mean).

 

[AlmostJesus]

Its funny, in the accompanying editorial they mentioned that in Pennsylvania, medics perform a median of 1 ET intubation per year, which tbh was surprising to me.

I dunno about you guys, but even at the slowest stations I've ever worked we would do at least 1 every other month (prob 6-10 per year). Although, it might just be different state/jurisdictional protocols and they prob also included part-time medics as well as those only working in EDs (plus its the median not the mean).

I recert this year, and I have only done one tube since I graduated... in the OR. I had one other opportunity for a tube and I had that taken from me.
I work part time in a slow system where I work in the ED too. We just don't see that many critical patients. Without RSI, it is becoming harder to justify it as a paramedic skill.

 

[Dzerzhinsky]

For those of you with more experience in EMS - after a major study like this finds something contradictory to current EMS dogma, how long does it usually take until we see a change in EMS practice/protocols?

Forever. And don't make the mistake of thinking that practice/protocols are equivalent. Practice lags protocols by five years or so (coughmumblefiremedicscough.)

There are those who advocate doing compressions only with an NRB in place for single rescuer codes. This may be the way we go in general.

Our protocols specify immediate intubation for codes. But, you know, codes are so busy and chaotic and there's just so much to doooooo, some of the more new-research-oriented types in my jurisdiction might just forget to drop the tube until ten minutes of CPR/defibrillation/meds has happened, at which point you can pretty much do whatever you want.

Its funny, in the accompanying editorial they mentioned that in Pennsylvania, medics perform a median of 1 ET intubation per year, which tbh was surprising to me.

I dunno about you guys, but even at the slowest stations I've ever worked we would do at least 1 every other month (prob 6-10 per year). Although, it might just be different state/jurisdictional protocols and they prob also included part-time medics as well as those only working in EDs (plus its the median not the mean).

Nope, not at all surprised. In rural areas like PA, they don't see that much. In resource-rich jurisdictions like mine, you're going to have 17 medics per code, so you've gotta run an average of 17 codes for every tube you actually get!

(Okay, not really 17. Eight. Actual number from the last code I was on.)

Plus, the median/mean thing you pointed out. Lots of medics are terrified of tubes (with good reason, really, given that it's something of a use-it-or-lose-it skill.) If they're terrified, they let the person who's not terrified do it, and that person gets more while they continue to bring down the average.

 

[jwk]

It may also have to do with the fact that either ETTs or supraglottic airways = better ventilation = they end up getting hyperventilated which we know is bad for outcomes.

Now there's a study. Current vs. fewer resps (e.g. 4/min) vs. no ventilation.

I think there's also a need for data on using lower O2 content such as RA. There is a lot of evidence that 100% O2 causes ozone/free radicle related lung damage. The question has been if this is offset by the tissue oxygen delivery increase of 100%. Hard to say and hard to study.

I know there is some passive ventilation that happens due to gas movement with compressions. This is primarily dead space ventilation but the thought is that the small amount of actual ventilation may be what makes compression only resus feasible. There are those who advocate doing compressions only with an NRB in place for single rescuer codes. This may be the way we go in general.

I think a lot depends on the abilities of those managing the airway, and most outside the anesthesia staff in the OR do it poorly. I can pop an ETT in without interrupting compressions in most cases, or it can easily be done when CPR is stopped for a few seconds for a pulse/rhythm check. BVM is actually a difficult skill to master, and unfortunately it's a slowly dying art, as even anesthesia providers now use LMA's during procedures where they used to use a mask and ventilated by hand.

We rarely see people hyperventilated with an ETT/LMA in place - and that shouldn't be an issue as more places utilize ETCO2 during an arrest as a guide to adequate CPR and/or ROSC.

 

[BB8730]

Forever. And don't make the mistake of thinking that practice/protocols are equivalent. Practice lags protocols by five years or so (coughmumblefiremedicscough.)

 

[joeDO2]

I recert this year, and I have only done one tube since I graduated... in the OR. I had one other opportunity for a tube and I had that taken from me.
I work part time in a slow system where I work in the ED too. We just don't see that many critical patients. Without RSI, it is becoming harder to justify it as a paramedic skill.

This is one of the reasons we see poor outcomes in some studies. People who intubate once a year cannot possibly maintain proficiency to the required level. I would say a minimum would be 10 intubations per year with periodic retraining on difficult airway scenarios. If unable to meet that mark, medics should either get the tubes in the OR or not be credentialed to perform the skill. This has been a debate for a number of years now. I see it becoming an optional skill for advanced practice medics or those in high volume systems only.

 

[docB]

I think a lot depends on the abilities of those managing the airway, and most outside the anesthesia staff in the OR do it poorly.

Ahem!

 

[alpinism]

This is one of the reasons we see poor outcomes in some studies. People who intubate once a year cannot possibly maintain proficiency to the required level. I would say a minimum would be 10 intubations per year with periodic retraining on difficult airway scenarios. If unable to meet that mark, medics should either get the tubes in the OR or not be credentialed to perform the skill. This has been a debate for a number of years now. I see it becoming an optional skill for advanced practice medics or those in high volume systems only.

Agreed, it takes a lot of practice to get comfortable w ETTs and even more to become proficient. Plus, practicing tubing in the well-lit controlled environment of the OR is NOT the same thing as doing it in the field. (I also don't like the instructional dummies many places are using now instead, although I guess its better than nothing...)

Realistically, in a perfect world, you'd want to practice a hundred times on many different types of patients before becoming certified. I didn't really start to feel comfortable until prob my 25th or 30th one. Only having 1 tube per year is dangerous.

We haven't even talked about peds/infant intubations yet...