ARTICLES DEALING WITH NASOTRACHEAL INTUBATION/OTHER ADVANCED LIFE SUPPORT AIRWAY ALTERNATIVES
| ARTICLE | CITATION | FEATURES/CONCLUSIONS |
|---|
| 1. Prehospital Blind NTI by Paramedics | Ann Emerg Med June 1989; 18:612-617 | Prospective study of prehospital use of NTI. 324 patients, success rate 66.7% trauma patients 72.2% medical patients. Frequency of use less than 4 attempts in 19 months success rate 71.3%. Serious complications 0.9%, included piriform sinus tear and esophageal placement. CL: blind NTI is a safe initial field airway approach in breathing patients without contraindications, even with low frequency of performance |
| 2. A Randomized Study Assessing the Systematic Search for Maxillary Sinusitis in NT Mechanically Ventilated Patients | Am J Respir Crit Care Med, Vol 159, pp 695-701, 1999 | Prospective (?) study of ICU patients to determine whether the detection of sinusitis by CT scan and treatment of it would decrease the incidence and need for treatment of ventilator assisted patient pneumonia. It did.
CL: the occurrence of VAP in patients undergoing prolonged mechanical ventilation via NTT can be prevented by the systematic search and tx of nosocomial sinusitis. |
| 3. Time to Intubation and Survival in Prehospital Cardiac Arrest | PEC, 2004;8:394-399 | Retrospective study of 693 prehospital patients intubated for cardiac arrest. Quick intubation group (less than or equal to 12" from collapse to intubation) 46% survival to discharge compared with slow intubation (greater than 13") 23% survival. Logistic regression used to adjust for confounding variables. Odds ratio of survival for slow vs. fast group 0.42 (95% CI 0.26, 0.69) CL: faster intubation times may increase odds of survival in prehospital cardiac arrest. |
| 4. Nasotracheal Intubation in the Emergency Department, Revisited | J of Emer Med, 17;5:791-799 | Retrospective study of 105 Emergency Department patients intubated by residents at a single hospital. Success rate was 79%. Complications included epistatxis, improper tube positions, sinusitis, pneumonia and sepsis. CL: NTI is a useful alternative to oral ETI particularly when oral access is compromised. Not the optimal approach, still a valuable method for establishing an airway by the emergency physician. |
| 5. The PTL, Combitube, Laryngeal Mask and Oral Airway: A Randomized Prehospital Comparative Study of Ventilatory Device Effectiveness and Cost-Effectiveness in 470 Cases of Cardiorespiratory Arrest | PEC 1997, 1:1-10 | Randomized, cross-over prehospital study of 470 patients in cardiac arrest. Non-ALS Emergency Medical Assistants (Canadian EMT-Intermediate equivalents) were trained in the use of the Pharyngeal Tracheal Lumen Airway, the Combitube, the LMA and BLS airway measures-laryngoscopy was not taught. Success rates were 86% Combitube, 82% PTL, 73% LM (p = 0.048). Subjective evaluation by the EMA's favored the Combitube, although ED evaluation of ventilation was mixed. There was no difference in survival between groups. The LMA had the cheapest operational cost per life saved, the Combitube the most expensive. CL: all 3 devices offered substantial advances over the Oral Airway/Bag Valve Mask management of the patients, the Combitube was associated with the least problems with ventilation and was the most preferred by the EMA's. |
| 6. Emergency Physician-Verified Out-of-hospital Intubation: Miss Rates by Paramedics | Acad Emer Med 2004;11:707-709 | Observational, prospective study of consecutive 208 intubated patients. 5.8% were incorrectly placed. Of these only 25% had the use of a verification device (e.g. end-tidal CO2 or Esophageal Detector Device) CL: the rate of unrecognized, misplaced out-of-hospital intubations in this urban setting was 5.8% |
| 7. Paramedic success rate for blind NTI is improved with the use of an endotracheal tube with directional tip control | Annals Emer Med, 36(4):328-332, Oct. 2000 | Consecutive, prospective study (non-randomized) of 219 Blind NTI's with intervention group of PM's trained to use ETT's with trigger activated distal tip control (intervention group) and conventional ETT's (control group). BNTI's successful 72 % of intervention group, and 58% in control group, with an overall success rate of 63%. CL: use of ETT's with distal directional control is associated with a higher success rate. |
| 8. Blind nasotracheal intubation for patients with penetrating neck trauma | J Trauma-injury Infection & Critical Care 56(5):1097-1101, May 2004 | Retrospective review of prehospital patients with penetrating neck trauma. Of 240 patients with PNT, 89 (37%) required airway management, and 40 (17%) underwent prehospital blind NTI. Success rate was 90% with a mortality rate of 5%. CL: patients managed with blind NTI did not experience complications related to the choice of airway management. The results of this study suggest that blind NTI may well be a valuable tool for the management of patients with penetrating neck trauma. |
| 9. An evaluation of out-of-hospital advanced airway management in an urban setting | Acad Emer Med 2005;12:417-22 | Prospective enrollment with retrospective chart review of 278 patients with prehospital airway interventions to identify placement of ETT and any complications identified. Of these patients, 55% had an initial NTI attempt and 45% had an initial OTI attempt. Success rates are not reported by type of intubation but the overall success rate was 84%. NTI's had a 2% rate of tube misplacement while OTI's had a 1% misplacement rate. CL: reasonable success and complications rates of ETI in the out-of-hospital setting can be achieved without the assistance of medications. |
| 10. Factors influencing successful intubation in the prehospital setting | Prehospital and Disaster Med 1995;10(4):259-264 | Prospective review of run reports and structured interviews of PM's on 236 prehospital intubations. Overall success rate 88% (NTI 85%, OTI 88%) Increased level of consciousness was associated with a decreased success rate, but oral vs. nasal route, scene time, PM seniority or # of attempts per paramedic were not. Factors reported to increase difficulty of ETI were: technical problems 35.6%, mechanical problems 15.6% and combative patients 12.7%. CL: multiple, including: oral ETI and NETI success rates are similar in this study to those described in the literature. Factors found to increase ETI difficulty could be ameliorated by the administration of paralytic agents, cadaver and recurring skills training would decrease difficulties with laryngoscopy. Interventions directed at alleviating mechanical difficulties should be explored including retrograde intubation, fiber-optic technology and surgical tracheal access. |
| 11. Failed Prehospital Intubations: An analysis of emergency department courses and outcomes | PEC 2001;5:134-141 | Retrospective chart review of prehospital records of 592 ETI attempts. Overall success rate was 90.5%. Of the 56 failed intubations, 49 charts were available. The failures were associated with inadequate relaxation 49%, difficult anatomy 20% and obstruction in 5%. Successful ETI was obtained in the E.D. on 86% of these 42 cases of failed prehospital ETI. 8 cases required multiple ETI attempts or rescue airways in the ED. The predicted minimum incidence of "truly difficult" airway in this system is approximately 0.8 - 1.6%. CL: paramedic intubation failures result from a variety of factors. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways. |
| 12. Populations at risk for intubation nonattempt and failure in the prehospital setting | PEC 2005;9:163-169 | Retrospective, observational study of oral ETI on pediatric cardiac arrest, adult traumatic arrest and adult cardiac arrest. 2,699 oral ETI's were included. Both groups (pedi cardiac and adult trauma arrest) individually showed significant risk for intubation non-attempt or failure compared with adult cardiac arrest. Pediatric cohort at higher risk for failure of attempt while Trauma cohort was at higher risk for non-attempt. CL: pediatric cohort at high risk for intubation attempt failure and adult trauma cohort at high risk for non-attempt of ETI. |
Protocols 9 - 10, 14 - 14.4, 43.1 - 44.3 (adult and pediatric resuscitation protocols): should there be any changes in current protocols to address imminent American Heart Association guideline changes for ACLS/PALS/PEPP/NRP?
Protocols 13 and 18 (hypothermia/near drowning): when should resuscitation be withheld from victims recovered from water incidents?
Protocol 19 (pain management): should the indications for use of morphine for pain control be expanded?
Protocol 20 (adult overdose): should paramedics switch from IV or IM narcan to intranasal narcan for treatment of certain types of opiate overdoses?
Protocol 47 (pediatric seizures): should paramedics return to giving valium per rectum for pediatric seizures and utilize diastat for this purpose?
Protocol 102 (Metropolitan Medical Response System); are current biologic and radiologic agent treatment protocols in alignment with Communicable Disease Control and Prevention guidelines?
San Francisco Emergency Medical Services Agency
