ET intubation vs. BVM

[leviathan]

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Has anyone heard about the study that was done that showed endotracheal intubation was no better at reducing mortality than using a bag-valve-mask? In fact, some of the values they reported had the BVM/control group with a higher survival rate.

If this is common knowledge to you guys, then what are the reasons for intubating? Just to prevent gastric distension, aspiration of vomitus/fluid, and keeping a secure airway?

-L

PS - I'll try to find a link to the study if anyone wants to see proof.

 

[NinerNiner999]

Yes - I've read some of the studies showing the relative efficacy of BVM, but a secure, intact airway is still the ideal situation. A BVM is only useful when ventilation is possible. Should the glottis close or the larynx spasm, there is no more airway. ET intubation protects the airway against collapse, aspiration, and provides defninitive delivery of oxygen to the lungs.

 

[Jeff698]

I know of several studies like that in the prehospital (paramedic) environment. I'd do a quick PubMed check but I'm too lazy right now. Sorry.

Take care,
Jeff

 

[leviathan]

I know of several studies like that in the prehospital (paramedic) environment. I'd do a quick PubMed check but I'm too lazy right now. Sorry.

Take care,
Jeff

Hey Jeff,

I think that's where I found it, but doesn't look like anyone is debating the fact so no worries. 🙂

 

[EMRaiden]

I haven't seem the study but in my personal practice I find that the patients who require intubation are generally the sicker patients (and thus have increased mortality). 🙂

There have been several studies out of San Diego looking at Paramedic Intubation showing that FIELD intubation is fraught with unrecognized complications, primarially prolonged hypoxia (several minutes), and that some severly head injured patients may be better off being bagged and not intubated...

 

[VentdependenT]

Aspiration pneumonia is a bitch. A well placed ET tube can help avoid this. Not to mention correcting acidotic states involved with this patient population,

 

[ERMudPhud]

Has anyone heard about the study that was done that showed endotracheal intubation was no better at reducing mortality than using a bag-valve-mask? In fact, some of the values they reported had the BVM/control group with a higher survival rate.

The studies you are talking about are all in the prehospital setting and mostly in pediatrics. I'm pretty sure intubation is a good thing in the ICU. 😀

 

[spyderdoc]

The studies you are talking about are all in the prehospital setting and mostly in pediatrics. I'm pretty sure intubation is a good thing in the ICU. 😀

Besides, try finding someone that is going to sit there for hours to days BVM'ing someone. Even if you strap the mask to the face and hook them up to a vent, someone has to be there at all times to make sure the bag does not dislodge or fill up with vomitus, etc.
Long term BVM is not very logistical or practical.

 

[docB]

Besides, try finding someone that is going to sit there for hours to days BVM'ing someone. Even if you strap the mask to the face and hook them up to a vent, someone has to be there at all times to make sure the bag does not dislodge or fill up with vomitus, etc.
Long term BVM is not very logistical or practical.

I'm assuming that we're talking about EMS here and that no one is advocating inpts being maintained on BVM. That would be insane.

As for the EMS angle I would argue that many aggressive therapies should not be used in the urban setting with short response and transport times. Doing a 3-5 min transport with BVM rather than ETT is perfectly feasible.

The problem with almost all EMS research is that it is done in urban areas because that's where the researchers are. In my view the places that really need all the aggressive field modalities are rural areas that have a 45 minute transport or a 20 minute wait for a helo. Thats where RSI, thrombolytics, crics, sternal IV guns, etc. could do the most good.

 

[spyderdoc]

I'm assuming that we're talking about EMS here and that no one is advocating inpts being maintained on BVM. That would be insane.

Has anyone heard about the study that was done that showed endotracheal intubation was no better at reducing mortality than using a bag-valve-mask? In fact, some of the values they reported had the BVM/control group with a higher survival rate.

If this is common knowledge to you guys, then what are the reasons for intubating? Just to prevent gastric distension, aspiration of vomitus/fluid, and keeping a secure airway?

-L

PS - I'll try to find a link to the study if anyone wants to see proof.

The OP doesn't really specify, but I guess it would be a good assumption that is what he meant....Makes more sense like that....

 

[leviathan]

The OP doesn't really specify, but I guess it would be a good assumption that is what he meant....Makes more sense like that....

I really didn't have a specification, because I don't exactly remember what the study was for itself anyhow. I just attributed higher mortality = poorer oxygenation.

The crux of what I was really getting at was how BVM compared to ETI for oxygenation efficiency.

 

[srlondon]

Outside of the parameters that some of the others have been posting about (urban areas with short transport time where "scoop & run" most always beats "stay & play"), ETI is an order of magnitude more effective and better for the patient for several reasons. 1) You have a cuffed endotracheal tube in the larynx directly ventilating the lungs. This allows lower pressures and higher efficiency right off the bat 2) BVM'ing a patient which non-selectivelly drives gas into the lungs and stomach and dramatically increases the risk of vomiting and aspiration 3) BVM'ing a patient with difficult anatomy (thick beards, short jaw or prominent maxilla) can be a sphincter-tightening experience and can require three people to do effectively in these cases (one to squeeze the bag, one to hold the mask to the face, and one to scrunch the cheeks and soft tissue up against the edges of the mask to improve the seal).

The crux of what I was really getting at was how BVM compared to ETI for oxygenation efficiency.

 

[roja]

I really didn't have a specification, because I don't exactly remember what the study was for itself anyhow. I just attributed higher mortality = poorer oxygenation.

The crux of what I was really getting at was how BVM compared to ETI for oxygenation efficiency.

EMRaiden makes a very valid point (if we aren't just talking about pre-hospital). You have to always look at these studies with a very critical eye. Is the increased mortality really due to the intubation or is the increased mortality secondary to the fact that patients need to be intubated are sicker?

Just to prevent gastric distension, aspiration of vomitus/fluid, and keeping a secure airway?

And these aren't 'just to' reasons... they are the CRUX of intubating. 🙂 all of these have incredibly serious complications if you don't deal with it...


And then, what happens if you cant bag? 😱


One of our resident is heading up a strong prospective study regarding EMS intubations (in the esophogus vs trach)

 

[Febrifuge]

these aren't 'just to' reasons... they are the CRUX of intubating. all of these have incredibly serious complications if you don't deal with it...

One of our residents is heading up a strong prospective study regarding EMS intubations (in the esophogus vs trach)

This points out, in just a tangential way, something I noted recently. A pt had been transferred in from one of the far-flung farming regions of the state, with a dual-lumen airway in place. Mention of the Combi-Tube elicited a couple of chuckles and eye-rolls at the Thursday morning conference, and yet those were mostly from people with no EMS training or expreience.

In the absence of an ET tube, and in a pre-hospital environment with a long trip in the near future, some of the people on the EM/ EMS side of the room thought the Combi made a lot of sense. Suctioning gastric gunk during a 40-minute heli ride would be easier if you know where the gunk is at all times, yes?

 

[12R34Y]

I personally have had good luck with combitubes. I think i've placed 3. all in code blues that we couldn't intubate after 3 attempts (company policy).

they worked well. got good breath sounds, good CO2 registering, no gurgling over belly etc....

only problem i had was that those things are so freaking huge that you really have to pull the mandible and tongue out to get those things in.

Most of the faculty at places where i transported to hated them though. don't really know why. they aren't at ET tube, but better than nothing. Of course it does make intubating easier after the combitube is in (if in the gut where it is supposed to be) because there is only one hole it CAN go into.......the trachea.

just some personal experience.

later