Improved mortality with laryngeal vs ET tube

[bravotwozero]

Anyone else heard of this? To be frank, I'm not sure what a 'laryngeal airway tube' is...I'm guessing it's not a king tube?

Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

Initial Laryngeal Tube Insertion vs Endotracheal Intubation Survival in Out-of-Hospital Cardiac Arrest

Thoughts?

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[Dr Mantis Toboggan]

Pretty sure it is the King.



Hail to the king, baby.

 

[DeadCactus]

I would think they mean any sort of supraglottic device. Honestly, this isn't new information. Study after study shows that urban patients would be better served by EMS systems that focus on perfecting the essential basics and getting the patient to the ED. Hell, even in the ED there is evidence that this obsession with shoving in an ET tube as quickly as possible is a suboptimal practice.

 

[DocRPP]

Dr. Wang presented this paper at the SAEM plenary this year. It was the King LT. Here is a link to the whole presentation if you are interested.

Conference.CAST

 

[WilcoWorld]

Agree with Cactus. I don't interpret this as showing that the King is a better airway device (personally, I would much rather switch out an LMA than a King LT).

Rather, I interpret this as (again) showing that EMS shouldn't "stay & play" when they've got short transport times.

 

[carbonizedeyesockets]

This has nothing to do with stay and play vs load and go. This has to do with poorly trained people who aren’t good at intubation being better off placing a blind insertion airway (eg King Ltd) instead. The medics involved in the study do not at all intubate frequently and generally do not intubate more than a small handful (around 5) of patients during training. Nothing surprising results, really.

Even with these results, EMS should continue to stay and play with cardiac arrests except in a few circumstances (eg trauma or hypothermia).

 

[Zebra Hunter]

This has nothing to do with stay and play vs load and go. This has to do with poorly trained people who aren’t good at intubation being better off placing a blind insertion airway (eg King Ltd) instead. The medics involved in the study do not at all intubate frequently and generally do not intubate more than a small handful (around 5) of patients during training. Nothing surprising results, really.

Even with these results, EMS should continue to stay and play with cardiac arrests except in a few circumstances (eg trauma or hypothermia).

Similar results from observational data of IHCA. Likely has little to do with intubater experience, more to do with focusing on what matters (high quality compressions and early defibrallation).

 

[WilcoWorld]

This has nothing to do with stay and play vs load and go. This has to do with poorly trained people who aren’t good at intubation being better off placing a blind insertion airway (eg King Ltd) instead. The medics involved in the study do not at all intubate frequently and generally do not intubate more than a small handful (around 5) of patients during training. Nothing surprising results, really.

Even with these results, EMS should continue to stay and play with cardiac arrests except in a few circumstances (eg trauma or hypothermia).

Fair enough, I may have overstated this study's applicability to the "stay & play" debate. But I think saying that this has nothing to do with that question is also lacking in subtlety of analysis.

 

[deleted109597]

There were 3 major studies, all of which basically pointed to the same conclusion. 1. Medics suck at RSI. 51% first pass success. 2. EGA is just as good at ventilating and oxygenating, and is way faster and easier. 3. Anything that reduces the amount of hands-off chest during CPR will improve survival.

 

[southerndoc]

Agree with Cactus. I don't interpret this as showing that the King is a better airway device (personally, I would much rather switch out an LMA than a King LT).

Rather, I interpret this as (again) showing that EMS shouldn't "stay & play" when they've got short transport times.

This is incorrect. In cardiac arrest situations, stay and play is the better approach. Higher ROSC, better provider safety (ever stood up to do CPR in the back of an ambulance?), etc. Medical directors seem to be pushing more field pronouncement. My crews do a lot of field pronouncements.

Wang did a similar study in 2012 that showed improved outcome in the ETI group. Benoit from Cincinnati did a nice meta-analysis published in Resuscitation. It pointed toward improved ROSC, survival to admission, and survival to discharge neurologically intact with ETI as opposed to a supraglottic airway.

Although Wang's latest article opens insight into further studies, I don't think it's a game changer and I don't foresee services not intubating based on that article.

On another note, we use a CPR puck device that attaches to our monitors. I can take a cardiac arrest from time of arrival and see how much force the medics are using for chest compressions, the rhythm while they are doing CPR, time of defibrillation, etc. There is audio recording. I can review compressions during intubation. Unlike what I see many ER docs do, my paramedics rarely stop compressions for intubation and they have extremely high (>95%) first pass success rates thanks to video laryngoscopy. Prior to video laryngoscopy, their first pass success was very low and they almost always stopped compressions. Since instituting that, plus a ResQ Pod and ResQ Pump system, our survival-to-discharge rate has gone from 3% to 7%. We're looking at other ways to improve this (PAD, etc.).

The paramedics are usually not first onscene. The EMT's use an iGel -- simple, effective, and no balloon to mess around with.

Regarding RSI, Georgia specifically forbids paramedics from using paralytics except with flight crews. The San Diego data showed that pre-hospital RSI is not a great thing.

 

[TheComebacKid]

I think stay and play is probably the way to go, however, ECMO is changing things. At our center we crash a select number of patients (usually refractory vfib arrest in a pseudo-healthy patient) onto ECMO. Most of the studies, coming out of Minneapolis, suggest you need to cannulate within 60 minutes and worse outcomes are associated with delays.

If ECMO becomes a thing, which it may or not (probably limited significantly by expense), stay and play will essentially fall to the wayside. Despite some press coming out of Europe, I don't see prehospital cannulation becoming a reality in the states, especially without a physician in the field.

With respect to the whole ETT vs supraglottic device issue, if you are still intubating your cardiac arrest patients, you are behind the times. We don't routinely intubate any of the cardiac arrest patients until if/when they receive ROSC. I find the I-Gel to be more than adequate to oxygenate/ventilate during arrest

 

[WilcoWorld]

This is incorrect. In cardiac arrest situations, stay and play is the better approach. Higher ROSC, better provider safety (ever stood up to do CPR in the back of an ambulance?), etc. Medical directors seem to be pushing more field pronouncement. My crews do a lot of field pronouncements.

Wang did a similar study in 2012 that showed improved outcome in the ETI group. Benoit from Cincinnati did a nice meta-analysis published in Resuscitation. It pointed toward improved ROSC, survival to admission, and survival to discharge neurologically intact with ETI as opposed to a supraglottic airway.

Although Wang's latest article opens insight into further studies, I don't think it's a game changer and I don't foresee services not intubating based on that article.

On another note, we use a CPR puck device that attaches to our monitors. I can take a cardiac arrest from time of arrival and see how much force the medics are using for chest compressions, the rhythm while they are doing CPR, time of defibrillation, etc. There is audio recording. I can review compressions during intubation. Unlike what I see many ER docs do, my paramedics rarely stop compressions for intubation and they have extremely high (>95%) first pass success rates thanks to video laryngoscopy. Prior to video laryngoscopy, their first pass success was very low and they almost always stopped compressions. Since instituting that, plus a ResQ Pod and ResQ Pump system, our survival-to-discharge rate has gone from 3% to 7%. We're looking at other ways to improve this (PAD, etc.).

The paramedics are usually not first onscene. The EMT's use an iGel -- simple, effective, and no balloon to mess around with.

Regarding RSI, Georgia specifically forbids paramedics from using paralytics except with flight crews. The San Diego data showed that pre-hospital RSI is not a great thing.

I'm confused - how do you interpret the article with respect to endotracheal intubation in the field?

 

[southerndoc]

I'm confused - how do you interpret the article with respect to endotracheal intubation in the field?

The latest Wang article? It supports SGA over ETI in the EMS systems where it was studied. Does not apply to all systems. Their paramedics are horrible at intubations (51.6% intubated initially), which complicates things.

 

[Hamhock]

The latest Wang article? It supports SGA over ETI in the EMS systems where it was studied. Does not apply to all systems. Their paramedics are horrible at intubations (51.6% intubated initially), which complicates things.

Are you saying that if EMS medics or EM docs could reliably intubate with 100% success and without stopping chest compressions, then you would recommend endotracheal intubation in cardiac arrest?

Would that be true if it was a witness arrest without a respiratory prodrome? Commotio cordis with less than one minute response time?
(the last one is an extreme example, I realize...but I think it makes my point)

HH

 

[southerndoc]

Are you saying that if EMS medics or EM docs could reliably intubate with 100% success and without stopping chest compressions, then you would recommend endotracheal intubation in cardiac arrest?

Would that be true if it was a witness arrest without a respiratory prodrome? Commotio cordis with less than one minute response time?
(the last one is an extreme example, I realize...but I think it makes my point)

HH

Yes, the data seems to favor ETI over SGA when patients can be reliably intubated.

However, the typical "ABC's" aren't followed. Early defibrillation is key. So just like with a major trauma where exsanguination is addressed before airway, the same is true of cardiac arrests: defibrillation trumps airway.

 

[gro2001]

This has nothing to do with stay and play vs load and go.

When did we change scoop and run to load and go? Medicine... always changing on ya.

 

[gro2001]

This is incorrect. In cardiac arrest situations, stay and play is the better approach. Higher ROSC, better provider safety (ever stood up to do CPR in the back of an ambulance?), etc. Medical directors seem to be pushing more field pronouncement. My crews do a lot of field pronouncements.

Wang did a similar study in 2012 that showed improved outcome in the ETI group. Benoit from Cincinnati did a nice meta-analysis published in Resuscitation. It pointed toward improved ROSC, survival to admission, and survival to discharge neurologically intact with ETI as opposed to a supraglottic airway.

Although Wang's latest article opens insight into further studies, I don't think it's a game changer and I don't foresee services not intubating based on that article.

On another note, we use a CPR puck device that attaches to our monitors. I can take a cardiac arrest from time of arrival and see how much force the medics are using for chest compressions, the rhythm while they are doing CPR, time of defibrillation, etc. There is audio recording. I can review compressions during intubation. Unlike what I see many ER docs do, my paramedics rarely stop compressions for intubation and they have extremely high (>95%) first pass success rates thanks to video laryngoscopy. Prior to video laryngoscopy, their first pass success was very low and they almost always stopped compressions. Since instituting that, plus a ResQ Pod and ResQ Pump system, our survival-to-discharge rate has gone from 3% to 7%. We're looking at other ways to improve this (PAD, etc.).

The paramedics are usually not first onscene. The EMT's use an iGel -- simple, effective, and no balloon to mess around with.

Regarding RSI, Georgia specifically forbids paramedics from using paralytics except with flight crews. The San Diego data showed that pre-hospital RSI is not a great thing.

If you haven't published your experience yet, you should!

 

[southerndoc]

If you haven't published your experience yet, you should!

Working on it.

 

[southerndoc]

The AIRWAYS-2 data is out (Benger, JAMA. 2018;320(8):779-791)

No difference in outcome with SGA vs ETI in cardiac arrest survival in the UK. Did not show SGA to have a statistically better ROSC, hospital discharge, etc. Survival was 6.8 vs 6.4% in the SGA and ETI groups, respectively. Major problem with the study was those randomized to have ETI were less likely to have advanced airway management (in other words, they weren't intubated and subsequently could not use an SGA as a rescue airway). If I'm interpreting the data correctly, only 77.4% of the ETI group were intubated.

 

[Hamhock]

Yes, the data seems to favor ETI over SGA when patients can be reliably intubated.

Are you referring to EMS data?
I am not familiar with this data for in-hospital or ER arrests. Please point me to this data.
HH

 

[southerndoc]

Are you referring to EMS data?
I am not familiar with this data for in-hospital or ER arrests. Please point me to this data.
HH

Meta-analysis by Benoit from Cincinnati.

 

[Hamhock]

Meta-analysis by Benoit from Cincinnati.

Yes, but this is EMS. (and debatable)
Your implication and answers to my questions implied you think this applies to cardiac arrest in general. That's why my post asked if you had data for in-hosptal or ER arrests (not OHCA or EMS).
HH

 

[Arcan57]

Yes, the data seems to favor ETI over SGA when patients can be reliably intubated.

However, the typical "ABC's" aren't followed. Early defibrillation is key. So just like with a major trauma where exsanguination is addressed before airway, the same is true of cardiac arrests: defibrillation trumps airway.

Outside of some very isolated examples, the whole concept of EMS reliably intubating in the field seems to be a pipe dream. If you wanted to spend enormous amounts of time and money having every paramedic rotate at least monthly through the OR where they manage multiple airways and equip them all with VL, I'm sure they'd have reasonable success rates. On the other hand, you could spend that same money teaching every EMT high quality CPR and throwing in an iGel, and maybe transporting them when they still have a chance of being resuscitated vs. the usual 17 rounds of epi (no other meds) in 40 minutes and dumping the patient in the ED after the patient's been persistently in asystole for the last half hour. Note my experience is in an urban area, where I think the concept of stay and play vs. load and go is still an open debate.

 

[d2305]

Epi is still the best. Pronouncing on scene sounds like a good idea.

 

[southerndoc]

Yes, but this is EMS. (and debatable)
Your implication and answers to my questions implied you think this applies to cardiac arrest in general. That's why my post asked if you had data for in-hosptal or ER arrests (not OHCA or EMS).
HH

I'm sorry, I misread your question. Anderson, et al. showed decreased survival to discharge with ETI in patients with IHCA.

 

[southerndoc]

Outside of some very isolated examples, the whole concept of EMS reliably intubating in the field seems to be a pipe dream. If you wanted to spend enormous amounts of time and money having every paramedic rotate at least monthly through the OR where they manage multiple airways and equip them all with VL, I'm sure they'd have reasonable success rates. On the other hand, you could spend that same money teaching every EMT high quality CPR and throwing in an iGel, and maybe transporting them when they still have a chance of being resuscitated vs. the usual 17 rounds of epi (no other meds) in 40 minutes and dumping the patient in the ED after the patient's been persistently in asystole for the last half hour. Note my experience is in an urban area, where I think the concept of stay and play vs. load and go is still an open debate.

I agree. Tons of resources are spent on airway management. I personally check off every paramedic in my system. They are required to have EtCO2 monitoring. I never fault a paramedic for inserting an iGel instead of intubating a patient. We are toying with the idea of removing intubation all together despite our success rate with video laryngoscopy, but we haven't decided yet.

Research seems to be mixed, but seems to suggest that ETI in OHCA is not helpful. My paramedics do not perform RSI and likely will never perform it both by state regulations as well as a decent amount of literature that shows it's not the best practice.

 

[DocRPP]

When are we gonna get these though?