Endotracheal Intubation to Supraglottic Airway Device

Endotracheal Intubation to Supraglottic Airway DeviceDiscussion Response 1Much debate has occurred recently some high failure rate and adverse effects associated with pre-hospital paramedic endotracheal intubation. Should ETT be removed entirely and replaced with supraglottic painsways?Maintaining an airway in a safe and effective modal value is critical in pre-hospital management of the unhurried in respiratory distress. The debate regarding the most appropriate device to manage this situation in the pre-hospital setting bequeath continue as devices and education and training of paramedics continues to improve.This discussion compares the failure rates and adverse effects of endotracheal intubation to supraglottic airway devices and discusses the possibility of removal of endotracheal tubes in spare of the office of supraglottic airways.The indications for endotracheal intubation for Victorian Paramedics are cardiac get a line, respiratory arrest, GCS greater than or equal to 10 with suspected airway burns (a consult is required), GCS little than 10 payable to respiratory failure, neurological injury, overdose, status epilepticus, hyperglycaemia with blood glucose level reading high or suspected airway burns. The paramedic requires clinical experience to recognise the 5 main indicators for intubation failure to ventilate, failure to oxygenate, inability to protect against aspiration, inability to maintain airway patency or predicting patient deterioration to respiratory failure (Lafferty Dillinger, 2016).Intubation success rates range from 69% to 98.4% the variation accounts for the level of education, training and case exposure. The success rate or lack thereof is directly proportional to the amount of education, training and case exposure received (Jacobs Grabinsky, 2014 and Piegeler, et al., 2016). In Australian studies it was found that Victorian HEMS based paramedics who underwent huge training that included hospital based practice (Bernard S . A., et al., 2015) attained 97% (Bernard S. , Smith, Foster, Hogan, Patrick, 2002) 100% (Andrew, et al., 2015) success rate. These intubations showed improvements with oxygen saturation, end tidal carbon dioxide levels, blood stuff (Bernard S. , Smith, Foster, Hogan, Patrick, 2002) and pain scores (Andrew, et al., 2015). There is a recommendation from the European Resuscitation Council that only well trained and experienced paramedics should perform endotracheal intubation and alternate airway devices should be used by less trained paramedics (Schalk, et al., 2012). Failure to maintain competency of this skill increases the risk of errors eliminating the benefits of endotracheal intubation and results in a negative patient publication (Tiah, et al., 2014).Endotracheal intubation is performed to ensure adequate ventilation system and oxygenation also to avoid aspiration of gastric contents or blood during cardio pulmonic resuscitation (Piegeler, et al., 2016) and when the airw ay is threatened due to oedema in the setting of facial burns or suspected inhalation burns (Price Milner, 2012). Improved patient outcomes were demonstrated when endotracheal intubation was successfully achieved compared to those with a supraglottic device, there was a higher incidence of return of spontaneous circulation, survival to hospital admission, neurologically intact, survival to hospital discharge. (Benoit, Gerecht, Steuerwald, McMullan, 2015).Temporary harm from airway management is plebeian however serious injury is not (Cook MacDougall-Davis, 2012). Complications attributed to endotracheal intubation are commonly hoarseness and sore throat, however patients can also experience lip swelling, laceration and bleeding, applauder laceration and bleeding, oral bleeding, dental damage, gingival bleeding, and pharyngeal bleeding (Toda, Toda, Arakawa, 2013). Failed intubation is associated with oxygen desaturation, hypertension, admission to ICU and complications at extu bating (Cook MacDougall-Davis, 2012). The risks associated with out of hospital endotracheal intubation are pulmonary aspiration, delay in transport due to several attempts, tube misplacement or difficult airway management. In these cases, where an invasive and time consuming technique may delay definitive care it may be more appropriate to utilise a supraglottic airway device as an alternative (Piegeler, et al., 2016).The indications for the use of a supraglottic airway device are unconscious patient without gag reflex, ineffective ventilation with BVM and oro- or nasal-pharyngeal airway, predicted greater than 10 minutes assisted ventilation required, or unable to intubate or difficult intubation (Ambulance Victoria, 2016). Many studies indicate a less than 1% failure rate of supraglottic airway devices (Cook MacDougall-Davis, 2012) this is due to the baseer education and training requirement and the device being less invasive (Jacobs Grabinsky, 2014). The failure rates were contributed to airway soiling and aspiration before paramedic treatment commenced. Proficiency of use is quickly attained (Haske, Schempf, Gaier, Niederberger, 2013), the device is faster to insert with higher success rate (Duckett, Fell, Kimber, Taylor, 2014) decreasing interruptions during a cardiac arrest and ventilation is possible with continuous compressions (Haske, Schempf, Gaier, Niederberger, 2013).The i-gel is a 2nd generation supraglottic airway device that exerts very low pressures on the pharyngeal mucosa resulting in low incidence of airway complication such as hoarseness and sore throat (Michalek, 2013). The major concerns of the use of any supraglottic airway device is the potential for air leak, airway, vocal cord and soft tissue injury, hypoxemia, and hypercapnia (Jacobs Grabinsky, 2014) and aspiration of gastric contents (Piegeler, et al., 2016). This generation of device is designed with a channel to insert a gastric tube to drain the stomach contents or air (Michalek, 2013) to prevent aspiration.Comparing placement success and time to ventilate when comparing single-handed endotracheal intubation and supraglottic airway device (Frascone, et al., 2011), hospital admission and survival to hospital discharge, and neurological or functional status (Tiah, et al., 2014) there is no significant divagation between the two types of devices (Frascone, et al., 2011 and Tiah, et al., 2014).In the metropolitan setting of paramedic practice there is a solid argument for the cessation of endotracheal use in prefer of a supraglottic device. The low level of education and training required to ensure proficiency, fast insertion time and the addition of the gastric tube channel on with the shorter transport times to definitive care indicates that a supraglottic airway is most appropriate airway device.ReferencesAmbulance Victoria. (2016). Clinical Practice Guidelines for Ambulance and MICA Paramedics (Revised Edition ed.). Doncaster, Victoria, Austra lia Ambulance Victoria. Retrieved March 19, 2017Andrew, E., de Wit, A., Meadley, B., Cox, S., Bernard, S., Smith, K. (2015, July/September). Characteristics of patients transported by a paramedic-staffed helicopter emergency medical service in Victoria, Australia. Prehospital Emergency Care, 19(3), 416 424. inside10.3109/10903127.2014.995846Benoit, J. L., Gerecht, R. B., Steuerwald, M. T., McMullan, J. T. (2015). Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arret A meta-analysis. Resuscitation, 93, 20 26. inside10.1016/j.resuscitation.2015.05.007Bernard, S. A., Smith, K., Porter, R., Jones, C., Gailey, A., Cresswell, B., . . . St Clair, T. (2015). Paramedic rapid sequence intubation in patients with non-traumatic coma. Emergency Medicine ledger, 32, 60 64. doi10.1136/emermed-2013-202930Bernard, S., Smith, K., Foster, S., Hogan, P., Patrick, I. (2002, December). The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury. Emergency Medicine Australasia, 14(4), 406 411. doi10.1046/j.1442-2026.2002.00382Bernhard, M., Mohr, S., A., W. M., Martin, E., Walther, A. (2012, February). Developing the skill of endotracheal intubation implication for emergency medicine. Acta Anaesthesiologica Scandinavica, 56(2), 164 171. doi10.1111/j.1399-6576.2011.02547Cook, T. M., MacDougall-Davis, S. R. (2012). Complications and failure of airway management. British Journal of Anaesthesia, 109(S1), i68 i85. doi10.1093/bja/aes393Duckett, J., Fell, P., Kimber, C., Taylor, C. (2014). Introduction of the i-gel supraglottic airway device for prehospital airway management in a UK ambulance service. Emergency Medicine Journal, 31, 505 507. doi10.1136/emermed-2012-202126Frascone, R. J., Russi, C., Lick, C., Conterato, M., Wewerka, S. S., Griffith, K. R., . . . Salzman, J. G. (2011). Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and s upraglottic airway. Resuscitation, 82, 1529 1536. doi10.1016/j.resuscitation.2011.07.009Haske, D., Schempf, B., Gaier, G., Niederberger, C. (2013). Performance of the i-gel during pre-hospital cardiopulmonary resiscitation. Resuscitation, 564, 72 77. doi10.1016/j.resuscitation.2013.04.025Jacobs, P., Grabinsky, A. (2014, January March). Advances in prehospital airway management. International Journal of deprecative Illness and Injury Science, 4(1), 57 64. doi10.4103/2229-5151.128014Lafferty, K. A., Dillinger, R. (2016, December 30). Rapid Sequence Intubation. (R. P. Byrd, Ed.) Retrieved March 19, 2017, from Medscape http//emedicine.medscape.com/article/80222-overviewa1Michalek, P. D. (2013). The I-Gel Supraglottic Airway. Nova Science Publishing Inc. Retrieved March 3, 2017, from http//ebookcentral.proquest.com/lib/vu/detail.action?docID=3022405Piegeler, T., Roessler, B., Goliasch, G., Fischer, H., Schlaepfer, M., Lang, S., Ruetzler, K. (2016, May). Evaluation of six contra sting airway devices regarding regurgitation and pulmonary aspiration during cardiopulmonary resuscitation (CPR) A human cadaver pilot study. Resuscitation, 102, 70 74. doi10.1016/j.resuscitation.2016.02.17Price, L. A., Milner, S. M. (2012). The totality of burn care. Trauma, 15(1), 16 28. doi10.1177/1460408612462311Schalk, R., Auhuber, T., Haller, O., Latasch, L., Wetzel, S., Weber, C. F., . . . Byhahn, C. (2012, January). Implementation of the laryngeal tube for prehospital airway management training of 1,069 emergency physicians and paramedics. Der Anaethesist, 61(1), 35 40. doi10.1007Tiah, L., Kajino, K., Alsakaf, O., Bautista, D. C., Ong, M., Lie, D., . . . Gan, H. N. (2014, November). Does Pre-hospital Endotracheal Intubation Improve Survival in Adults with Non-traumatic Out-of hospital cardiac Arrest? A Systematic Review. Western Journal of Emergency Medicine, XV(7), 749 757. doi10.5811/westjem.2014.9.20291Toda, J., Toda, A. A., Arakawa, J. (2013, October 17). Learning curve for paramedic endotracheal intubation and complications. International Journal of Emergency Medicine, 6(38). doi10.1186/1865-1380-6-38