Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents

doi:10.1016/S0735-6757(98)90027-4

The American Journal of Emergency Medicine

Volume 16, Issue 2, March 1998, Pages 125-127

https://doi.org/10.1016/S0735-6757(98)90027-4 Get rights and content

Abstract

To determine whether the success rate for endotracheal intubation improves after implementing the use of neuromuscular blocking (NMB) agents in an air medical program, this retrospective study analyzed all patients requiring endotracheal intubation at two air medical programs (nurse/paramedic crews) over a 5-year period. Air medical program A, the control group, had employed NMB agents throughout the entire study period. Air medical program B, which did not use NMB agents from July 1, 1989 through June 30, 1992, implemented their use starting July 1, 1992. For program A, the overall intubation success rate was 93.5% (202 successful intubations in 216 patients) and the successful intubations/total attempts ratio was 0.67 (202 of 301). For program B, the overall intubation success rate improved from 66.7% (46 successful intubations in 69 patients) before NMB agent use to 90.5% (57 in 63) after NMB agent use (P = .001). The successful intubations/total attempts ratio increased from 0.36 (51 of 141) prior to NMB agent use to 0.48 (63 of 132) after NMB agent use (P = NS). In comparing the 92 patients who did not receive NMB agents to the 40 patients who did, the intubation success rate increased from 69.6% (64 of 92) to 97.5% (39 of 40) (P < .001) and the successful intubation/total attempts ratio increased from 0.36 (73 of 202) to 0.58 (41 of 71) (P = .007). With the use of NMB agents, program B's overall intubation success rate increased significantly, matching the results of program A.

References (13)

JR Hedges et al.
Succinylcholine-assisted intubations in prehospital care
Ann Emerg Med
(1988)
SA Syverud et al.
Prehospital use of neuromuscular blocking agents in a helicopter ambulance program
Ann Emerg Med
(1988)
M Murphy-Macabobby et al.
Neuromuscular blockade in aeromedical airway management
Ann Emerg Med
(1992)
RM Walls
Airway management
Emerg Med Clin North Am
(1993)
RM Walls
Rapid sequence intubation in head trauma
Ann Emerg Med
(1993)
MR Sayre et al.
The use of neuromuscular blocking agents by air medical services
J Air Med Transport
(1992)

There are more references available in the full text version of this article.

Cited by (80)

Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department
2021, Journal of Emergency Medicine
Citation Excerpt :
It is unclear if the theoretical benefits of a ketamine-only approach outweigh the risks observed in the current study and how this approach compares with RSI when using a modern extraglottic device and cricothyrotomy as backup approaches. We do not know how patients would have fared if RSI was used instead, which provides full control of the patient, and has been shown in several studies and a systematic review to result in in better glottic views, higher success, and fewer complications compared with intubation with a sedative alone (4–7,16,17). In the current study, administration of a NMBA was the most common change for ketamine-only patients after the first attempt was unsuccessful.
Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach.
We compared first attempt success and complications between ketamine-only, topical anesthesia alone or with low-dose sedation, and RSI approaches.
We analyzed registry data from the National Emergency Airway Registry, comprising emergency department intubation data from 25 centers from January 2016 to December 2018. We excluded pediatric patients (<14 years of age), those in cardiac and respiratory arrest, or those with an alternate pharmacologic approach (i.e., neuromuscular blocking agent only or nonketamine sedative alone). We analyzed first attempt intubation success and adverse events across the 3 intubation approaches. We calculated differences in outcomes between the ketamine-only and topical anesthesia groups.
During the study period, 12,511 of 19,071 intubation encounters met inclusion criteria, including 102 (0.8%) intubated with ketamine alone, 80 (0.6%) who had intubation facilitated by topical anesthesia, and 12,329 (98.5%) who underwent RSI. Unadjusted first attempt success was 61%, 85%, and 90% for the 3 groups, respectively. Hypoxemia (defined as oxygen saturation <90%) occurred in 16%, 13%, and 8% of patients during the first attempt, respectively. At least 1 adverse event occurred in 32%, 19%, and 14% of the courses of intubation for the 3 groups, respectively. In comparing the ketamine-only and topical anesthesia groups, the difference in first pass success was −24% (95% confidence interval −37% to −12%), and the difference in number of cases with ≥1 adverse event was 13% (95% confidence interval 0–25%), both favoring the topical anesthesia group.
Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.
Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis
2017, Annals of Emergency Medicine
Citation Excerpt :
A comprehensive listing of the 89 articles undergoing qualitative assessment, including a description of the study characteristics, intubation success rates, and proportions of adverse effects, is shown in Table E1, available online at http://www.annemergmed.com. Eleven studies were nonrandomized trials,6,9,34-42 and 2 were randomized controlled trials.1,43 Twenty-five were prospective7,10,11,17,44-64 and 51 were retrospective studies.3-6,8,12,13,15,16,19,65-105
Rapid sequence intubation performed by nonphysicians such as paramedics or nurses has become increasingly common in many countries; however, concerns have been stated in regard to the safe use and appropriateness of rapid sequence intubation when performed by these health care providers. The aim of our study is to compare rapid sequence intubation success and adverse events between nonphysician and physician in the out-of-hospital setting.
A systematic literature search of key databases including MEDLINE, EMBASE, and the Cochrane Library was conducted. Eligibility, data extraction, and assessment of risk of bias were assessed independently by 2 reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success and for adverse events when possible.
Eighty-three studies were included in the meta-analysis. There was a 2% difference in successful intubation proportion for physicians versus nonphysicians, 99% (95% confidence interval [CI] 98% to 99%) versus 97% (95% CI 95% to 99%). A 10% difference in first-pass rapid sequence intubation success was noted between physicians versus nonphysicians, 88% (95% CI 83% to 93%) versus 78% (95% CI 65% to 89%). For airway trauma, bradycardia, cardiac arrest, endobronchial intubation, hypertension, and hypotension, lower prevalences of adverse events were noted for physicians. However, nonphysicians had a lower prevalence of hypoxia and esophageal intubations. Similar proportions were noted for pulmonary aspiration and emesis. Nine adverse events estimates lacked precision, except for endobronchial intubation, and 4 adverse event analyses showed evidence of possible publication bias. Consequently, no reliable evidence exists for differences between physicians and nonphysicians for adverse events.
This analysis shows that physicians have a higher rapid sequence intubation first-pass and overall success, as well as mostly lower rates of adverse events for rapid sequence intubation in the out-of-hospital setting. Nevertheless, for all success and adverse events no firm conclusion for a difference could be drawn because of lack of precision of meta-analytic estimates or selective reporting. First-pass success could be an area in which to focus quality improvement strategies for nonphysicians.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 6. Paediatric life support.
2015, Resuscitation
Citation Excerpt :
Oral intubation is quicker and simpler, and is associated with fewer complications than nasal intubation. In the conscious child, the judicious use of anaesthetics, sedatives and neuromuscular blocking drugs is essential to avoid multiple intubation attempts or intubation failure.128–137 Only skilled and experienced practitioners should perform intubation.
Supraglottic airway device use as a primary airway during rapid sequence intubation
2013, Air Medical Journal
This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls.
Rotor-wing division of a single critical care transportation company
53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO₂, ETCO₂ at 2 minutes after placement, and complications were also analyzed.
38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12–46). Pre- and post-insertion SaO¹₂ values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO₂ at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient's airway was the most frequently reported complication (46%).
Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.
Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for child tracheal intubation?
2012, Annales Francaises d'Anesthesie et de Reanimation
Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?
2012, Annales Francaises d'Anesthesie et de Reanimation

View all citing articles on Scopus

^☆: Presented at the 1995 Society for Academic Emergency Medicine Annual Meeting, May 24, 1995, San Antonio, TX.

View full text

Original contributionIntubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents☆

Abstract

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

J Air Med Transport

Original contribution
Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents☆