Intubacjaprzedszpitalna–koniecznaczyniebezpieczna?

Drmed.MarzenaWojewódzka-ŻelezniakowiczUniwersyteckiSzpitalKlinicznywBiałymstoku

IXOgólnopolskaKonferencjaMedycynyRatunkowej„Kopernik2016”

Częstośćwykonywaniaprocedurprzedszpitalnie

•  Dostępdożylnyobwodowy(28,4%),•  monitorowanieczynnościserca(16,1%)•  Pulsoksymetria(13,5%),•  glikemia(10,4%)•  kardiowersja,defibrylacjaintubacjadotchawiczabyłyrzadko

wykonywane(2,4%).

CarlsonJN,KarnsC,MannNC,EJacobsonK,DaiM,ColleranC,WangHE.ProceduresPerformedbyEmergencyMedicalServicesintheUnitedStates.PrehospEmergCare.2016;20(1):15-21

Intubacjadotchawiczaq wymagadoświadczenia

q wwarunkachprzedszpitalnychzawszetrudna

q niezawszewykonalna

q proceduradłuższaniżwprzypadkumetodnadgłośniowychq niebezpiecznadlapacjentaq mogąjąwykonywaćlekarze,ratownicymedyczniw

przypadkuNZK

Skutecznośćintubacji

skuteczność

Czynnikiogólne

Czynnikipacjenta

Doświadczenieosoby

intubującej

Skutecznośćintubacji

skuteczność

Czynnikiogólne

Czynnikipacjenta

Doświadczenieosoby

intubującej

ZAGROŻENIA

Wytyczneresuscytacjikrążeniowo-oddechowej2015r.

Theriskofanunrecognisedmisplacedtrachealtube–inpaientswithout-of-hospitalcardiacarrestthereliablydocumentedincidencerangesfrom0.5%to17%emergencyphysicians–0.5%paramedics–2.4%

6% 9%

17%GrmecS.Comparisonofthreedifferentmethodstoconfirmtrachealtubeplace-mentinemergencyintubaion.IntensiveCareMed2002;28:701–4.LyonRM,FerrisJD,YoungDM,McKeownDW,OglesbyAJ,RobertsonC.Fieldintubaionofcardiacarrestpaients:adyingart?EmergMedJ:EMJ2010;27:321–3.JonesJH,MurphyMP,DicksonRL,SomervilleGG,BrizendineEJ.Emergencyphysician-verifiedout-of-hospitalintubaion:missratesbyparamedics.AcadEmergMed:OffJSocAcadEmergMed2004;11:707–9.PelucioM,HalliganL,DhindsaH.Out-of-hospitalexperiencewiththesyringeesophagealdetectordevice.AcadEmergMed:OffJSocAcadEmergMed1997;4:563–8.

JAKOŚĆ

Przerwywuciskaniuklatkipiersiowej

IntubacjadotchawiczawNZK

•  Ocenadługościokresubezuciskaniaklatkipiersiowejpodczasintubacji–przedszpitalnie

•  Analiza100zatrzymańkrążenia•  Intubacjaprzezparamedyków•  Medianaczasutrwaniapierwszejintubacjidotchawiczej

wynosiła46,5sekundy(IQR23,5do73sekund,min.7maks.221sekund);1/3przekroczyła1min.

•  całkowityczastrwaniaprzerwwRKOzwiązanychzpróbamiintubacjitchawicywynosił110s(IQR54-198s,zakres13-446s)

•  w25%przerwawynosiła3min.

WangHE,SimeoneSJ,WeaverMD,CallawayCW.Interrupionsincardiopulmonaryresuscitaionfromparamedicendotrachealintubaion.AnnEmergMed2009;54,645-52e1.

METODY

Wybórmetody-paramedycy

VossS,RhysM,CoatesD,etal.Howdoparamedicsmanagetheairwayduringoutofhospitalcardiacarrest?Resuscitaion2014;85:1662–6.

•  OHCA,paramedycy•  196RKO•  Początkowo–maska-woreksamorozprężalny55%•  SAD–20%•  TI-25%•  71%intubacjidotchawiczychskutecznych

•  dalszeinterwencjeu64%(SAD)•  uchorychintubowanych76%niewymagałodalszych

interwencjiPodobnaskutecznośćwwmetod

IntubacjadotchawiczavsSADIntubacjadotchawiczawpozaszpitalnymzatrzymaniukrążenia:•  zmniejszailośćpowikłańneurologicznych•  Zmniejszaśmiertelność.

WangHE,SzydloD,StoufferJA,etal.Endotrachealintubaionversussupraglowcairwayinserioninout-of-hospitalcardiacarrest.Resuscitaion2012;83:1061–6.TanabeS,OgawaT,AkahaneM,etal.Comparisonofneurologicaloutcomebetweentrachealintubaionandsupraglowcairwaydeviceinserionofout-of-hospitalcardiacarrestpaients:anaionwide,populaion-based,observaionalstudy.JEmergMed2013;44:389–97.

Ale….Właściwieprzeprowadzona

Intubacjawobrażeniachczaszkowo-mózgowych

2008-2012rok,27,714pacjentów,badaniekohortowe

parametr TI nonTI p

Czasnamiejscuzdarzenia(min) 9 8 p<0,001

czastransportu(min.) 26 19 p<0,001

GCSwSOR(bezsedacji) 3,7 3,9 p=0,026

wentylacjamechaniczna(dni) 7,3 6,9 p=0,006

pobytwICU(dni) 6,0 5,0 p<0,001

pobytwszpitalu(dni) 10,0 9,0 p<0,001

śmiertelnośćwewnątrzszpitalna 31,4% 27,5%, p<0,001

HaltmeierT1,BenjaminE1,SiboniS1,DilektasliE1,InabaK1,DemetriadesD2.Prehospitalintubaionforisolatedsevereblunttraumaicbraininjury:worseoutcomesandhighermortality.EurJTraumaEmergSurg.2016Aug27.

Intubacjawobrażeniachczaszkowo-mózgowych

•  Wanalizieregresjiintubacjaprzedszpitalnabyłaniezależnymczynnikiemryzyka:

•  niższejpktwGCS•  wyższejśmiertelnościwszpitalu(OR1,399,CI1,205/1,624,p

<0,001).

HaltmeierT1,BenjaminE1,SiboniS1,DilektasliE1,InabaK1,DemetriadesD2.Prehospitalintubaionforisolatedsevereblunttraumaicbraininjury:worseoutcomesandhighermortality.EurJTraumaEmergSurg.2016Aug27.

ExperienceinPrehospital

EndotrachealIntubaionSignificantlyInfluencesMortality

ExperienceinPrehospitalEndotrachealIntubaionSignificantlyInfluencesMortalityofPaientswithSevereTraumaicBrainInjury:ASystemaicReviewandMeta-Analysis.PLoSOne.2015Oct23;10(10):e0141034.

BossersSM1,SchwarteLA2,LoerSA1,TwiskJW3,BoerC4,SchoberP2.

intubacjadotchawicza

intubacjadotchawiczapozaszpitalnawykonywanaprzezpersonelmedycznynie

posiadającydoświadczeniazwiększaśmiertelnośćwśródpacjentów

BossersSM1,SchwarteLA2,LoerSA1,TwiskJW3,BoerC4,SchoberP2.Experience in Prehospital Endotracheal Intubaion SignificantlyInfluences Mortality of Paients with Severe Traumaic Brain Injury: ASystemaic Review and Meta-Analysis. PLoS One. 2015 Oct23;10(10):e0141034.

not know the actual diagnosis but have to treat patients based on the suspected diagnosis, andtherefore, including these studies makes the results more applicable to the real-life situation.Other differences in in- and exclusion criteria, geographical differences, and differences in howthe intubations were performed (with or without anaesthetic drugs) can all introduce heteroge-neity and bias. We therefore used a random-effects model for the meta-analysis to accommo-date for such heterogeneity, and indeed, substantial heterogeneity was observed. However,most of the heterogeneity vanished after adjusting for EMS-provider experience in the meta-regression, indicating that experience is the single most important factor in explaining thosedifferences between the studies that are not attributable to chance.

It was necessary to assign a level of experience to each study. Experience is rather abstractand difficult to quantify, and we therefore used the pragmatic approach to dichotomize experi-ence as “limited” or “extended”. To avoid bias due to misclassification, three investigators per-formed this assessment and a level was assigned by unanimous consensus. With this carefulapproach, we can exclude that any study in which EMS-provider experience was actually “lim-ited”may have been misclassified as “extended” experience or vice versa. The sensitivity

Fig 2. Forrest plot. Forrest plot summarizing the individual studies and pooled results of the meta-analysis. The relationship between prehospital intubation(PHI) and mortality is stratified by experience of prehospital healthcare providers.

doi:10.1371/journal.pone.0141034.g002

Traumatic Brain Injury and Prehospital Endotracheal Intubation

PLOS ONE | DOI:10.1371/journal.pone.0141034 October 23, 2015 21 / 26

SKUTECZNOŚĆ

Naukaićwiczenia

Istniejąnieliczne(bardzoróżniącesię)daneopisujące,jakdługonależyćwiczyćintubacjędotchawicząabyosiągnąćodpowiedniowysoki

wskaźnikskuteczności90-95%.

106 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2010 VOLUME 14 / NUMBER 1

100%

90%

80%

70%

60%

50%0 5 10 15 20

Overall Success

First-Pass Success

Cumulative Prehospital Intubation

Pre

hosp

ital E

TI S

ucce

ss R

ate

FIGURE 1. Mean prehospital endotracheal intubation (ETI) success rates are graphed (solid line) with 95% confidence intervals (dashed lines) foroverall ETI success rates (regardless of number of attempts) and first-pass ETT placement. Whereas data for mean student overall ETI successbegin to plateau between 10 and 15 prehospital ETIs, there is no plateau for first-pass success up to 20 prehospital ETIs, suggesting that morethan 20 prehospital ETIs are required to achieve appropriate first-pass ETI success. Note that this figure is constructed only from data collectedin the prehospital ETI setting and does not include ETIs performed in other settings (e.g., operating room, emergency department).

have access to a university-affiliated surgical facility,support from the anesthesia faculty, a rigorous qual-ity assessment program providing real-time monitor-ing of student progress, and ample clinical opportunityfor ETI training.

Despite our findings, prehospital ETI by paramedicsis still controversial. Several authors, including an ex-pert panel, attribute the lack of efficacy of prehos-pital ETI in preventing mortality to low ETI successrates, complicating factors such as hypoxia and hyper-ventilation, and system issues that may impair ade-quate paramedic training and skills maintenance.7,10

Many systems capture only placement of the ETT,without accounting for other factors such as hypoxia,hyper- and hypoventilation, aspiration, and multi-ple laryngoscopic attempts. The need to reduce theseimportant complications suggests that training goals

TABLE 3. Factors Contributing to Increasing Odds of OverallSuccess in Paramedic Intubations

Adjusted GEE 95% ConfidenceAll-Pass Success Odds Ratio Interval

ETI number 1.097 1.026–1.173Cardiac arrests 1.045 0.454–2.405Trauma 0.904 0.482–1.697RSI 0.949 0.432–2.081

Odds of overall intubation success were higher for each successive patient,demonstrating the effect of cumulative experience on overall intubation suc-cess.ETI number = cumulative number of ETIs by student; GEE = generalizedestimating equations; RSI = rapid-sequence induction.

should focus on first-pass ETI success. Currently, fewprehospital systems have reported first-pass successrates for ETI, but those reported range from 62% to75%.3,11

The minimum educational standards established forprehospital ETI by the National Highway Traffic SafetyAdministration (NHTSA) Emergency Medical Techni-cian Paramedic: National Standard Curriculum maynot be adequate to guarantee subsequent success inETI. The NHTSA document specifies that studentsshould achieve a minimum of five successful ETIsprior to graduation,12 a number that is discordant withminimums established for other intubating providers.This level is well below the recommended level of 35ETIs for emergency medicine residents.13 Anesthesi-ology residents reportedly must perform between 45and 60 ETIs to achieve at least a 90% success rate in

TABLE 4. Factors Contributing to Increasing Odds ofFirst-Pass Success in Paramedic Intubations

Adjusted GEE 95% ConfidenceFirst-Pass Success Odds Ratio Interval

ETI number 1.061 1.014–1.109Cardiac arrests 1.263 0.698–2.286Trauma 0.836 0.552–1.266RSI 1.575 0.831–2.985

Odds of first-pass intubation success were higher for each successive patient,demonstrating the effect of cumulative experience on first-pass intubationsuccess.ETI number = cumulative number of ETIs by student; GEE = generalizedestimating equations; RSI = rapid-sequence induction.

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liberalnezałożenieprogramówszkoleniowychopisuje7intubacjiwykonanychprzezjednegostudentaabyopanowaćtechnikęNiezbędnejest25-50intubacjirocznieabyosiągnąćskutecznośćintubacji90%.

WangHE,SeitzSR,HostlerD,YealyDM.Definingthelearning24.curveforparamedicstudentendotrachealintubaion.PrehospEmergCare.2005;9:156–62.

Warunkipozaszpitalne

Skutecznośćintubacji

•  2007do2010rok•  Prospektywnebadaniejednoośrodkowe•  Rezydencianestezjologii•  25 intubacji dotchawiczych w 15,6 ± 3,0 dnia – 67%

skuteczności•  52%rezydentów-200intubacjiwykonałow50.2±14.8

tyg.–83%(pierwszejpróby)92%wszystkich,(p<0.0001)•  Ilość prób intubacji zmniejszyła się z 1,6 ± 0,8 po

pierwszych25ETIdo1,3±0,6po200ETI.(p=0,0001).

BernhardM,MohrS,WeigandMA,MarinE,WaltherA.Developingtheskillofendotrachealintubaion:implicaionforemergencymedicine.ActaAnaesthesiolScand2012;56:164–71.

Szkolenie•  „ekspertintubacji”szkolonypodintensywnymnadzoremlekarza,

•  Odbywającycyklicznykompleksowyprogramszkoleniowy,

•  nadzórlekarzanamiejscuzdarzenia

•  odnotowanobardzowysokiodsetekudanychTIzarównodladzieciidorosłych

WarnerKJ,CarlbomD,CookeCR,BulgerEM,CopassMK,ShararSR.Paramedictrainingforproficientprehospitalendotrachealintubaion.PrehospitalEmergCare.2010;14:103–8.

SirbaughPE,PepePE,ShookJE,etal.Aprospecive,populaion-basedstudyofthedemographics,epidemiology,managementandoutcomeofout-of-hospitalpediatriccardiopulmonaryarrest.AnnEmergMed.1999;33:174–84.

glare and pupillary constriction for the rescuers. Thiscircumstance requires that the practitioners are taughtand understand the ‘tricks of the trade’, such as placing acoat or blanket over one’s head (and the head of thepatient) in order to create a makeshift darkened room akinto an old-time photographer’s camera hood. In contrast,even in the dark of night, heavy rain or awkward confinedspaces may pose their own barriers to easily visualizingvocal cords. Therefore, many of the classical techniquesused by other practitioners in more traditional settingswould not be as effective in the fast-paced, poorlycontrolled and mobile prehospital settings where resourcesand support are limited (Figure 1).In turn, a key to successful EMS intubation in the

out-of-hospital setting is the street-wise experience ofexpert highly-experienced medical trainers and EMSmedical directors who not only understand these princi-ples, but also are themselves facile in such techniques inthe out-of-hospital setting [5,6,12].

Frequent skill usage and system staffing configurationsEven if initial training techniques are expert andwell-taught, both in the classroom and on-scene, frequencyof performance is a critical factor. For example, studieshave shown the success rates for ETI can be related to thedeployment strategy of the EMS system [2,3,32,33]. InEMS systems using tiered ambulance deployments inwhich paramedics (ALS providers) are spared for the mostcritical calls, many fewer paramedics are needed on theroster and the individual experience of each paramedic,including frequency of ETI performance, can be enhanced

dramatically [2,32]. Accordingly, this approach has beencorrelated with improved success rates in terms of ETIperformance [2,32].This need to enable frequent experience is critical in

EMS. While ETI skills may deteriorate a little with ahiatus from practice, collective experience [2,32] hasdemonstrated that most prehospital personnel who haveperformed ETI a hundred times or more in the out-of-hospital setting may still be able to perform the techniquequite well despite the hiatus. However, the key issue isgetting to that threshold of experience and this prerequisitegoal requires high exposure and frequent performance.Unfortunately, that level of performance is not alwaysachieved in most EMS systems today. As an example, for afive-year ‘veteran’ paramedic to have achieved a successfulETI over 100 times, it would mean successful performanceof that procedure at least 20 times a year for five years.Most paramedic units are usually staffed by two paramedics,so if ETI experience were to be shared with a paramedicpartner, the implication is that this particular team wouldneed to face 40 ETI situations a year on their particularambulance and shift. In fact, accounting for sick time,vacation time and other factors, it typically takes 5 to 6fulltime equivalent paramedics to staff one of those twopositions and thus 10–12 different paramedics will beneeded just for that one ambulance around the clock.Therefore, that particular response unit would need to faceapproximately 200 to 250 ETI cases a year for each ALSprovider to get 20 opportunities to intubate.Considering that cardiac arrest, respiratory distress

and major trauma cases requiring ETI constitute only2–3% of all EMS on-scene emergency responses [32],the ambulance in question would need to experiencenearly 10,000 EMS incidents a year overall. In mostEMS system configurations, this level of volume would bea logistical-temporal impossibility for a single ambulance.Unless alternate deployment strategies were to be utilized,frequent exposure to ETI cases would be clearly limited.Indeed, alternative deployments are key. Specifically,

in some communities, paramedics (or other types ofALS personnel, such as doctors or nurses) are sparedfrom the majority of EMS responses. Instead of ALSproviders, basic emergency medical technicians (EMTs)trained to do the non-invasive procedures such as spinalimmobilization and splinting are used for most of theresponses [2,3,32,33]. Under such circumstances, overallstaffing could, therefore, involve a much smaller cadre ofparamedics. This would permit more frequent exposureto critical illness and injury for the individual paramedics(ALS providers). The same concept would apply tonurses or apprentice physicians who staff ambulancesand air medical units, particularly in some Europeancountries [2,32,33]. The fact that air medical units aretypically triaged only to the most critical cases means

Figure 1 Endotracheal intubation in the out-of-hospital setting.In the early years of out-of-hospital emergency medical services (EMS)systems, advanced life support personnel were not only trained in thenuances of how to avoid overzealous ventilation and properly place anendotracheal tube in very challenging circumstances, but they werealso well-supervised on-scene by expert physicians who themselveswere highly-experienced and exceptionally familiar with thosechallenges as well as methods to overcome them (photo byDr. Paul Pepe).

Pepe et al. Critical Care (2015) 19:121 Page 3 of 7

PepePE1,2,RoppoloLP3,4,FowlerRL5,6.CritCare.2015Mar16;19:121.Prehospitalendotrachealintubaion:elementalordetrimental?

Skutecznośćintubacji

•  Wykonanieminimum40intubacjiroczniepodnadzoremlekarza

•  Wwarunkachnaturalnych(codziennejpracy)

PepePE1,2,RoppoloLP3,4,FowlerRL5,6.Prehospitalendotrachealintubaion:elementalordetrimental?CritCare.2015Mar16;19:121.

Skutecznośćintubacji

MyersLA1,GalletCG1,KolbLJ2,LohseCM3,RussiCS2.DeterminantsofSuccessandFailureinPrehospitalEndotrachealIntubaion.WestJEmergMed.2016Sep;17(5):640-7.

•  200intubacji•  Zespołyparamedyk/paramedykzespółszkolonywwykonywaniu

intubacjidotchawiczejlubparamedyk/technikratownictwa•  25%niepowodzeń•  Trzykrotniewyższaskutecznośćintubacjiwprzypadkuzespołu

paramedyk/paramedyk•  Użycierurkiintubacyjnejorozmiarze<7.0wiązałosięzponad4-

krotnymzwiększeniemskutecznościintubacji•  Widoknagłośniczęściowy–prawie13krotniezwiększał

skutecznośćintubacji•  Widoknagłośnicałkowityprawie40krotniezwiększał

skutecznośćintubacji(OR,39,78)

AHA2010rok

Accordingtotheguidelinesforcardiopulmonaryresuscitaiongivenbythe

AmericanHeartAssociaionin2010,frequentexperienceorfrequentretrainingisrecommendedforproviderswhoperformETI.

Wnioski

Kompetencjewarunkowanepotwierdzonymiumiejętnościami

wnioski

•  Zmianaprogramukształceniaratownikówmedycznych

•  Powtarzaneszkoleniezumiejętności•  Zróżnicowaniekompetencjiratownikówmedycznych•  Kursyukierunkowanenawykonywanieprocedur•  Warunkujetoodpowiednieprzygotowaniedosamodzielnejpracy