1/9/2015. Red Flags in Prehospital Airway Management. H. Wang, MD 1. Red Flags in Prehospital Airway Management. Disclosures. The Current Standard

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1 Red Flags in Prehospital Airway Henry E. Wang, MD, MS Professor and Vice Chair for Research Department of Emergency Medicine University of Alabama at Birmingham Disclosures NIH Grant Support UH2-HL U01-HL U01-HL R01-NR Site PI, Resuscitation Outcomes Consortium PI, Pragmatic Airway Resuscitation Trial The Current Standard Prehospital endotracheal intubation (ETI) Performed by paramedics for a long time Standard of care for over 25 years Procedure that defines paramedic level care Science has raised numerous red flags H. Wang, MD 1

2 Does Prehospital Intubation Save Lives? >20 studies of prehospital intubation and outcome (survival) Recurrent theme: Prehospital intubation associated with increased risk of death Prehospital intubation associated with poorer neurological outcome Intubation of Children Gausche, JAMA 2000 Controlled trial 830 pediatric patients Alternated ETI/BVM with BVM-only No difference in survival No difference in neurological outcome Pediatric Intubation Does Not Save Lives RSI for TBI Davis, J Trauma 2003 Multicenter implementation of prehospital Rapid Sequence Intubation 209 pts compared with 627 historical controls RSI associated with increased death OR: 1.6 [ ] Prehospital RSI Does Not Save Lives (and May Harm). H. Wang, MD 2

Intubation of TBI Ann Emerg Med 2004 Pennsylvania Statewide Data, 2000-2002 N=4,000

ED Intubation Prehospital ETI 4x higher odds of death Prehospital ETI 1.

Outcomes Due to Adverse Events and Errors?

3 Intubation of TBI Ann Emerg Med 2004 Pennsylvania Statewide Data, N=4,000 Severe TBI Compared EMS vs. ED Intubation Prehospital ETI 4x higher odds of death Prehospital ETI 1.6x higher odds of poor neuro outcome Prehospital Intubation May Harm TBI Are Poor Outcomes Due to Adverse Events and Errors? Endotracheal Tube Misplacement Katz and Falk, Ann Emerg Med 1999 N=108 Prehospital intubations Systematic reconfirmation in ED 25% tube misplacement rate 2/3 esophageal 1/3 above vocal cords H. Wang, MD 3

4 Dunford, et al. Ann Emerg Med 2004 San Diego RSI Trial Subset of 152 RSI patients Out of 462 from total trial Continuously recorded waveforms: Heart Rate Oxygen Saturation End-Tidal Capnography Dunford, et al. Ann Emerg Med 2004 SaO2 HR ETCO2 Dunford, et al. Ann Emerg Med 2004 Desaturation and Bradycardia Dunford, et al. Ann Emerg Med 2004 San Diego RSI Trial, n=152 Oxygen desaturation: 31 (57%) Median duration: 160 seconds (IQR 48 to 272) Median desaturation (SpO2): 22% Bradycardia: 6 (19%) Pulse rate <50 beats/min Paramedics described intubation as "easy" in 84% H. Wang, MD 4

Intubation Hyperventilation BAD Known to be bad in TBI Vent pco2 Cerebral

Vent Intrathoracic Pressure Coronary Perfusion Aufderheide: Crit Care Med

Intubation and CPR Chest Compressions Example of Chest Compression

5 Intubation Hyperventilation BAD Known to be bad in TBI Vent pco2 Cerebral Perfusion Davis DP, et al: J Trauma 2004 Jul;57(1):1-8 May be bad during CPR Vent Intrathoracic Pressure Coronary Perfusion Aufderheide: Crit Care Med 2004;32(9 Suppl):S Aufderheide: Circulation 2004; Intubation and CPR Chest Compressions Example of Chest Compression Interruption from Intubation 30 sec CPR Interruption ETCO 2 Signal ET Tube Placement H. Wang, MD 5

Intubation-Associated Chest Compression Interruptions Percentage of Patients 0 10 20 30 40 Median: 2 Interruptions (IQR: 1-3) Min 1, Max 9 30% >2 Interruptions 1 2 3 4 5 6 7 8 9 Total Number of CPR

6 Intubation-Associated Chest Compression Interruptions Percentage of Patients Median: 2 Interruptions (IQR: 1-3) Min 1, Max 9 30% >2 Interruptions Total Number of CPR Interruptions Wang, et al., Ann Emerg Med 2009 Pittsburgh, n=100 Duration of Intubation-Associated Chest Compression Interruptions First Subsequent First CPR Interruption Median: 46.5 sec (IQR: ) Min 7, Max 221 ~30% >60 sec Subsequent CPR Interruptions Median: 35 sec (IQR: 21-58) Min 7, Max 199 ~20% >60 sec Sum Sum of All CPR Interruptions Median: sec (IQR: ) Duration (sec) Min 13, Max 446 ~25% >180 sec Wang, et al., Ann Emerg Med 2009 Are We as Good as We Think? H. Wang, MD 6

Prehospital Intubation Success Rates Meta Analysis Hubble, et al. PEC 2010 Meta analysis of >100 studies Intubation Success Rates Pooled 86.3% Cardiac arrest 91.2% RSI 96.

7 Prehospital Intubation Success Rates Meta Analysis Hubble, et al. PEC 2010 Meta analysis of >100 studies Intubation Success Rates Pooled 86.3% Cardiac arrest 91.2% RSI 96.1% Cardiac Arrest Intubation Success NEMSIS 2008 WEST 89.2% ( %) NE: 56,844 ND: 39,705 MIDWEST 85.4% ( %) NORTHEAST 79.7% ME: 92,986 MN: 627,393 ( %) NH: 60,278 IA: 141,216 NJ: 899 NC: 2,085,369 NV: 86,535 CO: 222,290 AL: 270,775 Not Included Partially Included NM: 16,797 OK: 3,844 MO: 131,654 FL: 523,455 Included Hawaii: 23,728 Wang, et al. Resuscitation 2010 SOUTH 70.0% ( %) Intubation Success Rates - Cardiac Arrests First-pass success 70% 100% 90% 84.9% 89.9% 91.2% 91.6% 91.8% 100.0% 80% 70% 69.9% 69.9% ETI Success (%) 60% 50% 40% 57.8% 55.6% 46.5% 41.7% 30% 20% 10% 0% ETI Attempt Cumulative Attempt Success Individual Attempt Success Wang, et al. Acad Emerg Med 2006 H. Wang, MD 7

8 Does Skill Play a Role? Intubation is Difficult in the Prehospital Mosh Pit Intubation is Difficult in the Prehospital Mosh Pit There s no such thing as an easy Prehospital airway Paramedics need exceptional intubation skills H. Wang, MD 8

9 How Many Tubes Do You Need to Graduate in the US? Emergency Med Residents 35 Anesthesia Residents CRNA Students 200 Paramedic Students 5 Paramedic Student ETI Learning Curve Wang, et al., Prehosp Emerg Care 2005 Magic Number: ETI Paramedic Student Operating Room Training Hours Median hours Percentage of Programs hrs 5-8 hrs 9-16 hrs hrs >32 hrs OR Hours Johnston, et al., Acad Emerg Med 2006 H. Wang, MD 9

Program Director Frustration We are seeing ORs completely shut out paramedic students. Our local hospital [anesthesia] group refuses to have students in the OR.

10 Program Director Frustration We are seeing ORs completely shut out paramedic students. Our local hospital [anesthesia] group refuses to have students in the OR. Students must drive two hours each way for OR experience. We had a hospital for intubations until they said we would be required to pay. Securing OR time for ETI is the single most difficult aspect of my job as program director. Mannequins and Simulators? Few studies Plastic Flesh Levitan: Plastic does not recreate the mush of live structures Sim-man cannot recreate Jabba s airway Sim-man cannot recreate heterogeneity of airways Intubation Skill Skill ( Proficiency ) = Baseline Training + Regular Application H. Wang, MD 10

.. Should paramedics Prehospital ETI is (very) complex and intubate at difficult all?

11 Number of Tubes Per Paramedic Pennsylvania 2003 Median ETI: 1 (IQR 0-3) 39% performed no ETI 67% performed 2 or fewer ETI Wang, et al. Crit Care Med 2005 ETI Across Pennsylvania Houston, We Have a Problem... Should paramedics Prehospital ETI is (very) complex and intubate at difficult all? No proven clinical benefit Prone to error (some unrecognized) Interacts with other interventions Performed under worst possible conditions Limited training H. Wang, MD 11

There is an Alternative Supraglottic Airway

Easy to insert in any position Ventilate as

generation Supraglottic Airways Instead of

reliable Put it in Forget about it MOVE ON

12 There is an Alternative Supraglottic Airway Devices Easy to learn Lower training burden Easy to insert in any position Ventilate as well as ET tubes Improvement with each generation Supraglottic Airways Instead of Intubation COMMON SENSE SGAs simple, easy, reliable Put it in Forget about it MOVE ON TO THE MORE IMPORTANT PARTS OF RESUSCITATION H. Wang, MD 12

13 It s Already Happening in the USA Kalamazoo, MI Chesterfield County, VA Collier County, FL Dallas, TX Paramedics substituting ETI with Combitube/King for cardiac arrests Decreased CPR hand-off time Increased ROSC/survival best figures in 15 years Where do we go from here? Take-Home Messages Do not stop intubating Have a healthy respect for airway management Far more complex than we imagine Maximize airway training opportunities Airway QA is mandatory Need to keep an open mind to new (unpopular) ideas H. Wang, MD 13

achieving airway management You must choose the right mouse trap at the right time It s Not Over til the Fat Lady

14 How Do I Sell This to My Medics? The clinical objective is airway management Endotracheal intubation is one option - among several options - for achieving airway management You must choose the right mouse trap at the right time It s Not Over til the Fat Lady Sings Prehospital Intubation and Outcomes Cardiac Arrest Hasegawa, et al. JAMA 2013 Japan All-Utstein N=650,000 Advanced airway lower survival than BVM OR 0.38 (95% CI, ) H. Wang, MD 14

15 Prehospital Intubation and Outcomes Cardiac Arrest Nascent EMS system ETI and SGA are new procedures Few SGA Even fewer ETI No field termination protocols [ETI & SGA] vs no airway Not ETI vs SGA Confounding by indication Uncertain data validity Resuscitation Outcomes Consortium ETI vs. SGA in Cardiac Arrest 10,455 OHCA 8,457 ETI 1,968 SGA 909 King 296 Combitube 239 LMA 518 Unknown ETI Wins over SGA (Oops ) Resuscitation 2012 H. Wang, MD 15

16 46 N=5,591 N=3,110 N=1, McMullan, Resuscitation 2014 H. Wang, MD 16

17 A Randomized Trial? REVIVE-Airways and Airways-2 UK Study Phase I Feasibility Study ETI vs I-Gel vs LMA- Supreme Phase II Clinical Trial ETI vs I-Gel Enrollment starting in 2015 Approx n=9,000 Pragmatic Trial of Advanced Airway Strategies in Out-of-Hospital Cardiopulmonary Arrest H. Wang, MD 17

18 Pragmatic Airway Resuscitation Trial (PART) NIH Funded UH2-HL Special RFA for Pragmatic Trials US ROC Sites RCT of Airway Strategies Primary ETI Primary King LT Primary Outcome: 72-Hour Survival Anticipated Enrollment: N=2,612 Starting Fall 2015 Endotracheal Intubation Advanced EMS: ETI Basic EMS: BVM Adult Out-of-Hospital Cardiac Arrest CONTINUE RESUSCITATION Laryngeal Tube Advanced EMS: LT Basic EMS: BVM (or LT) Some Thoughts on Drug-Facilitated Intubation Do You Need OR Time for RSI? There are no data to support this, so I m not requiring it for my RSI medics Strongest RSI programs have incorporated OR time Wayne, PEC 2001 OR for baseline training Requirement: 12 ETI/year or else to OR >2000 RSI over 20 years very few complications We know this works H. Wang, MD 18

Can RSI Potentially Help? Maybe Bernard, Ann Surg 2010 Australian RCT in adult TBI Prehospital RSI vs. Supportive Airway RSI improved 6-mos functional outcome Good (egos 5-8) vs.

19 Can RSI Potentially Help? Maybe Bernard, Ann Surg 2010 Australian RCT in adult TBI Prehospital RSI vs. Supportive Airway RSI improved 6-mos functional outcome Good (egos 5-8) vs. Poor (egos 1-4) Relative Risk 1.28; No differences in primary endpoint (median egos) or other endpoints (!) 16 hours RSI training, including OR time 97% RSI success rate Rapid-Sequence Airway (RSA)? Braude, et al. PEC 2007 Etomidate + Roc + LMA (Etomidate + Sux + King) Sensible strategy Paranoia of RSI is the I - not the RS King airway easy, reliable, robust If we embraced safer airway techniques, we could (safely) entertain novel airway strategies Sedation-Facilitated Intubation? Strong consensus Sedation-facilitated intubation requires same system and patient safeguards as for RSI Formulary availability qualification to perform technique Etomidate-only? Jacoby, et al., Ann Emerg Med 2006 Irony no difference in success rates vs. Versed H. Wang, MD 19

University of Alabama School of Medicine 619 19 th

20 Questions? Contact Henry E. Wang, MD, MS Department of Emergency Medicine University of Alabama School of Medicine th St. South, OHB 251 Birmingham, AL (205) H. Wang, MD 20

Pearls for ED Airway Management 12/26/2013

Pearls for ED Airway Management 12/26/2013 Red Flags in Prehospital Airway Management Henry E. Wang, MD, MS Associate Professor and Vice Chair for Research Department of Emergency Medicine University of Alabama at Birmingham The Current Standard