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July 31, 2015

Airway management: The equipment and technique debate continues

If polled, it is reasonable to expect EMS personnel to rank advanced airway management as one of the most important prehospital interventions. Despite this attitude, numerous studies and case reports highlight the complications associated with advanced airway management, especially when inexperienced providers attempt to perform endotracheal intubation.[1-4] The American Heart Association acknowledges the lack of adequate evidence to recommend a specific advanced airway or to recommend the optimal timing for device insertion relative to other advanced procedures.[5]

Airway error types

Researchers recently proposed a classification system for errors and complications created when attempting to use an advanced airway.[6] This system includes technical errors, cognitive errors, and adverse anatomic effects.

Technical errors associated with advanced airway placement include airway misplacement[7], multiple failed attempts[8], prolonged attempts[9], and accidental dislodgement after correct placement.[10] Technical errors may decrease ventilation effectiveness[11] and increase the frequency and duration of interruptions in chest compressions during a resuscitation attempt.[12]

Cognitive errors deal with the knowledge needed to perform a skill. EMS personnel must know the advantages and disadvantages of each of the different type of advanced airway devices, and well as the indication for use. Examples of cognitive errors in advanced airway management include patient assessment errors, failure to troubleshoot airway problems, and overcompensation for oxygenation and ventilation deficiencies. Overcompensation, in the form of hyperventilation is common in traumatic brain injury management[13] and during resuscitation attempts following cardiac arrest that occurs both in the out-of-hospital[14] and in-hospital settings.[15-17]

Post - ROSC arterial hyperoxia (a potential consequence of overcompensation) has also been shown to decrease survival to hospital discharge rates in adult patients who suffered cardiac arrest.[18] Although arterial hyperoxia increases oxygen content of the blood, it also reduces regional perfusion through vasoconstriction.[19] The net effect is decreased oxygen delivery to the organs and tissues.

The final category of errors and complications are those that produce anatomic abnormalities. For example, esophageal-tracheal tube insertion can result in tracheal injury, upper airway bleeding, tongue edema, or esophageal laceration or perforation.[20] Overinflation of the laryngeal tube cuffs can cause swelling in the tongue significant enough to produce life-threatening airway obstruction.[21] Complications related to the endotracheal intubation involving anatomic abnormalities include tongue perforation[22] and tracheal laceration.[23,24]

Although trauma related to the use of endotracheal tube introducers is rare, most complications result from railroading, whereby the healthcare provider aggressively and forcefully pushes the endotracheal tube over the bougie even after meeting resistance.[25] Use of the bougie has resulted in bronchial laceration[26], pharyngeal wall perforation[27], bleeding and blood clot formation in a mainstem bronchus[28], and tracheal perforation resulting in a complete intratracheal airway obstruction.[29]

Using the most appropriate device

Despite the problems associated with advanced airway placement, EMS personnel can improve patient ventilation by inserting a supraglottic airway when compared to ventilation with a bag-mask even when the EMS provider has only limited training in advanced airway management.[30] A recent investigation demonstrated that early insertion of a supraglottic airway significantly improved chest compression fraction when compared to bag-mask ventilation in patients who suffered an out-of-hospital cardiac arrest.[31] This study did not measure survival outcomes however; other studies have demonstrated improvements in clinical outcomes with higher chest compression fractions.[32-34] The increase in chest compression fraction observed in the study is likely due to the change in compression/ventilation ratios that followed advanced airway insertion.

KISS principle applies

EMS providers should strive to keep things simple when deciding which airway device to use in a specific situation. Specifically for the paramedic practitioner, the airway toolbox is filled with a multitude of devices and procedures for establishing and maintaining airway patency. Paramedics should consider the following:

  • the anatomic presentation of the airway
  • the environment in which the patient presents
  • the confidence of their ability to perform the procedure reliably and accurately
  • the ability of the device or procedure to preserve airway patency, and
  • the potential for complications and untoward outcomes with the device

In general, the simpler the device or procedure, the greater the reliability and accuracy of its use. However, not all anatomic presentations or environmental conditions are conducive to simpler devices. EMS providers should be not only well versed in how to use every device and procedure available, but also to critically decide when to use the appropriate method and what other choices need to be used in case of failure.

Current and future studies

Researchers in France are currently investigating whether the use of an endotracheal tube improves 28-day survival with favorable neurological outcome following out-of-hospital cardiac arrest compared to use of bag-mask ventilation.[35] The study is expected to conclude mid-year 2017.

Researchers in the United Kingdom are studying out-of-hospital cardiac arrest and comparing outcomes between 9,000 adult patients whose airways were managed with an endotracheal tube and those managed with a second generation supraglottic airway. [36] The primary outcome for the study, known as the UK AIRWAYS-2 study, is neurological outcome (as measured by the modified Rankin scale) at hospital discharge. Enrollment began early this year and is expected to conclude in late 2017.

Later this year, the Resuscitation Outcomes Consortium will begin enrolling patients into the Pragmatic Airway Resuscitation Trial (PART [ClinicalTrials.gov Identifier: NCT02419573]). For adult patients who develop cardiac arrest in the out-of-hospital environment, researchers will randomly allocate those patients to receive early advanced airway management with either an endotracheal tube or  laryngeal tube.[37] The primary outcome for the study will be 72-hour survival. By the time the study concludes in late 2020, the researchers expect to enroll 3,000 patients.

References

1. Cobas, M., De la Pena, M. A., Manning, A., & Varon, A. J. (2009). Prehospital intubations and mortality: A level one trauma center perspective. Anesthesia and Analgesia, 109(2), 489–493. doi:10.1213/ane.0b013e3181aa3063

2. Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., Poore, P. D., McCollough, M. D., Henderson, D. P., Pratt, F. D., & Seidel, J. S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. Journal of the American Medical Association, 283(6), 783–790. doi:10.1001/jama.283.6.783

3. Katz, S. H., & Falk, J. L. (2001). Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine, 37(1), 32–37. doi:10.1067/mem.2001.112098

4. Wirtz, D. D., Ortiz, C., Newman, D. H., & Zhitomirsky, I. (2007). Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehospital Emergency Care, 11(2), 213–218. doi:10.1080/10903120701205935

5. Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., Kudenchuk, P. J., Ornato, J. P., McNally, B., Silvers, S. M., Passman, R. S., White, R. D., Hess, E. P., Tang, W., Davis, D., Sinz, E., & Morrison, L. J. (2010). Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122[suppl 3], S729–S767. doi:10.1161/CIRCULATIONAHA.110.970988

6. Benoit, J. L., Prince, D. K., & Wang, H. E. (2015). Mechanisms linking advanced airway management and cardiac arrest outcomes. Resuscitation, 93, 124-127. doi: 10.1016/j.resuscitation.2015.06.005

7. Jones, J. H., Murphy, M. P., Dickson, R. L., Somerville, G. G., & Brizendine, E. J. (2004). Emergency physician-verified out-of-hospital intubation: Miss rates by paramedics. Academic Emergency Medicine, 11(6), 707–709. doi:10.1197/j.aem.2003.12.026

8. Studnek, J. R., Thestrup, L., Vandeventer, S., Ward, S. R., Staley, K., Garvey, L., & Blackwell, T. (2010). The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Academic Emergency Medicine, 17(9), 918-925. doi:10.1111/j.1553-2712.2010.00827.x

9. Wayne, M. A., & McDonnell, M. (2010). Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation. Prehospital Emergency Care, 14(2), 278-282. doi:10.3109/10903120903537189

10. Park, S. H., Han, S. H., Do, S. H., Kim, J. W., & Kim, J. H. (2009). The influence of head and neck position on the oropharyngeal leak pressure and cuff position of three supraglottic airway devices. Anesthesia and Analgesia, 108(1), 112-117. doi:10.1213/ane.0b013e318192376f

11. Davis, D. P., Hoyt, D. B., Ochs, M., Fortlage, D., Holbrook, T., Marshall, L. K., & Rosen, P. (2003). The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Journal of Trauma, 54(3), 444-453. doi:10.1097/01.TA.0000053396.02126.CD

12. Wang, H. E., Simeone, S. J., Weaver, M. D., & Callaway, C. W. (2009). Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Annals of Emergency Medicine, 54(5), 645-652. doi:10.1016/j.annemergmed.2009.05.024

13. Davis, D. P., Dunford, J. V., Ochs, M., Park, K., & Hoyt, D. B. (2004). The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. Journal of Trauma, 56(4), 808-814. doi:10.1097/01.TA.0000100217.05066.87

14. Aufderheide, T. P., Sigurdsson, G., Pirrallo, R. G., Yannopoulos, D., McKnite, S., von Briesen, C., Sparks, C. W., Conrad, C. J., Provo, T. A., & Lurie, K. G. (2004). Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation, 109(16), 1960-1965. doi:10.1161/01.CIR.0000126594.79136.61)

15. (Abella, B. S., Alvarado, J. P., Myklebust, H., Edelson, D. P., Barry, A., O'Hearn, N., Vanden Hoek, T. L., & Becker, L. B. (2005). Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. Journal of the American Medical Association, 293(3), 305-310. doi:10.1001/jama.293.3.305

16. Losert, H., Sterz, F., Köhler, K., Sodeck, G., Fleischhackl, R., Eisenburger, P., Kliegel, A., Herkner, H., Myklebust, H., Nysaether, J., & Laggner, A. N. (2006). Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Archives of Internal Medicine, 166(21), 2375-2380. doi:10.1001/archinte.166.21.2375

17. O'Neill, J. F., & Deakin, C. D. (2007). Do we hyperventilate cardiac arrest patients? Resuscitation, 73(1), 82-85. doi:10.1016/j.resuscitation.2006.09.012

18. Kilgannon, J. H., Jones, A. E., Shapiro, N. I., Angelos, M. G., Milcarek, B., Hunter, K., Parrillo, J. E., & Trzeciak, S. (2010). Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. Journal of the American Medical Association, 303(21), 2165-2171. doi:10.1001/jama.2010.707

19. Iscoe, S., Beasley, R., & Fisher, J. A. (2010). Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest. Journal of the American Medical Association, 304(13), 1440-1441. doi:10.1001/jama.2010.1397

20. V´ezina, M. C., Tr´epanier, C. A., Nicole, P. C., & Lessard, M. R. (2007). Complications associated with the esophageal–tracheal Combitube in the pre-hospital setting. Canadian Journal of Anaesthesia, 54(2), 124–128. doi:10.1007/BF03022008

21. Schalk, R., Seeger, F. H., Mutlak, H., Schweigkofler, U., Zacharowski, K., Peter, N., & Byhahn, C. (2014). Complications associated with the prehospital use of laryngeal tubes--a systematic analysis of risk factors and strategies for prevention. Resuscitation, 85(11), 1629-1632. doi:10.1016/j.resuscitation.2014.07.014

22. Lollo, L., Meyer, T. K., & Grabinsky, A. (2012). A rare complication of tracheal intubation: tongue perforation. Case Reports in Anesthesiology, 2012, 281791. doi:10.1155/2012/281791

23. Chen, E. H., Logman, Z. M., Glass, P. S., & Bilfinger, T. V. (2001). A case of tracheal injury after emergent endotracheal intubation: A review of the literature and causalities. Anesthesia and Analgesia, 93(5), 1270-1271. doi:10.1097/00000539-200111000-00047

24. Üzümcügil, F., Babaoglu, G., Denizci, E., Sar?caoglu, F., & Kanbak, M. (2015). Tracheal laceration as a complication of out-of-hospital emergency tracheal intubation in a patient with COPD. American Journal of Emergency Medicine, 33(1), 128.e1-3. doi:10.1016/j.ajem.2014.06.021

25. Phelan, M. P. (2004). Use of the endotracheal bougie introducer for difficult intubations. American Journal of Emergency Medicine, 22(6), 479-482. doi:10.1016/j.ajem.2004.07.017

26. Sahin, M., Anglade, D., Buchberger, M., Jankowski, A., Albaladejo, P., & Ferretti, G. R. (2012). Case reports: Iatrogenic bronchial rupture following the use of endotracheal tube introducers. Canadian Journal of Anesthesia, 59(10), 963-967. doi:10.1007/s12630-012-9763-z

27. Kadry, M., & Popat, M. (1999). Pharyngeal wall perforation – an unusual complication of blind intubation with a gum-elastic bougie. Anaesthesia, 54(4), 404-405. doi:10.1046/j.1365-2044.1999.00875.x

28. Prabhu, A., Pradhan, P., Sanaka, R., & Bilolikar, A. (2003). Bougie trauma – it is still possible. Anaesthesia, 58(8), 811-813.

29. Arndt, G. A., Cambray, A. J., & Tomasson, J. (2008). Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction. Anesthesia and Analgesia, 107(2), 603-604. doi:10.1213/ane.0b013e318176fe36)

30. Roth, D., Hafner, C., Aufmesser, W., Hudabiunigg, K., Wutti, C., Herkner, H., & Schreiber, W. (2015). Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardiac arrest. American Journal of Emergency Medicine, 33(8), 1050-1055. doi:10.1016/j.ajem.2015.04.048

31. Maignan, M., Koch, F. X., Kraemer, M., Lehodey, B., Viglino, D., Monnet, M. F., Pham, D., Roux, C., Genty, C., Rolland, C., Bosson, J. L., Danel, V., & Debaty, G. (2015). Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study. Resuscitation, 93, 113-117. doi: 10.1016/j.resuscitation.2015.06.002

32. Bobrow, B. J., Vadeboncoeur, T. F., Stolz, U., Silver, A. E., Tobin, J. M., Crawford, S. A., Mason, T. K., Schirmer, J., Smith, G. A., & Spaite, D. W. (2013). The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Annals of Emergency Medicine, 62(1), 47-56. doi:10.1016/j.annemergmed.2012.12.020

33. Rea, T., Olsufka, M., Yin, L., Maynard, C., & Cobb, L. (2014). The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation, 85(7), 879-884. doi: 10.1016/j.resuscitation.2014.02.026

34. Yannopoulos, D., Aufderheide, T. P., Abella, B. S., Duval, S., Frascone, R. J., Goodloe, J. M., Mahoney, B. D., Nadkarni, V. M., Halperin, H. R., O'Connor, R., Idris, A. H., Becker, L. B., & Pepe, P. E. (2015). Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation, pii: S0300-9572(15)00248-8. doi:10.1016/j.resuscitation.2015.06.004

35. ClinicalTrials.gov. (2015). Tracheal intubation vs. bag-valve-mask ventilation in patients with out-of-hospital cardiac arrest - CAAM STUDY [ClinicalTrials.gov Identifier: NCT02327026]. Retrieved from https://clinicaltrials.gov/ct2/show/NCT02327026?term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=1

36. BioMed Central. (2015).  Airway management in out of hospital cardiac arrest patients [ISRCTN08256118]. Retrieved from http://www.isrctn.com/ISRCTN08256118?q=ISRCTN08256118&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search

37. ClinicalTrials.gov. (2015). Pragmatic airway resuscitation trial (PART). Retrieved from https://clinicaltrials.gov/ct2/show/NCT02419573?term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=2

About the Author

Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail kenny.navarro@ems1.com.
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