Two Hundred Sixty Pediatric Emergency Airway Encounters ......Pediatric airway management was guided...

Two Hundred Sixty Pediatric Emergency AirwayEncounters by Air Transport Personnel

A Report of the Air Transport Emergency Airway Management(NEAR VI: ‘‘A-TEAM’’) Project

William Wallace Tollefsen, MD,*Þþ Calvin A. Brown, III, MD,*§ Kelly L. Cox, MD,||and Ron M. Walls, MD*§

Background: Effective airway management is the cornerstone ofresuscitative efforts for any critically ill or injured patient. The role andsafety of pediatric prehospital intubation is controversial, particularlyafter prior research has shown varying degrees of intubation success.We report a series of consecutive prehospital pediatric intubations per-formed by air-transport providers.Methods: We retrospectively reviewed intubation flight records froman 89-rotorcraft, multistate emergency flight service during the timeperiod from January 1, 2007, to December 31, 2009. All patients youn-ger than 15 years were included in our analysis. We characterized pa-tient, flight, and operator demographics; intubation methods; successrates; rescue techniques; and adverse events with descriptive statistics.We report proportions with 95% confidence intervals and differencesbetween groups with Fisher exact and W

2 tests; P G 0.05 was consideredsignificant.Results: Two hundred sixty pediatric intubations were performedconsisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8%(n = 257) underwent an orotracheal intubation attempt as the firstmethod. First-pass intubation success was 78.6% (n = 202), and intu-bation was ultimately successful in 95.7% (n = 246) of cases. Medicaland trauma intubations had similar success rates (98% vs 95%, Fisherexact test P = 0.3412). There was no difference in intubation successbetween age groups (W2 = 0.26, P = 0.88). Three patients were managedprimarily with an extraglottic device. Rescue techniques were used in11 encounters (4.2%), all of which were successful. Cricothyrotomywas performed twice, both successful.Conclusions: Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highlysuccessful. This effect on patient outcome requires further study.

Key Words: prehospital, helicopter, intubation

(Pediatr Emer Care 2013;29: 963Y968)

Out-of-hospital tracheal intubation is an accepted practice;however, there is wide variability in tracheal intubation

performance by prehospital personnel. Prior research on para-medic intubation performance and patient outcomes after pre-hospital intubation has yielded mixed results.1Y6 Study in

pediatric populations has demonstrated similar findings.7Y9 Inaddition, some evidence suggests prehospital use of bag-valve-mask ventilation may be equivalent to endotracheal intubationfor hypoxic and hypopneic children.9 Given this, some agen-cies are no longer including pediatric tracheal intubation as partof a prehospital airway protocol. Difficulties with pediatricprehospital intubations can stem from low intubation volume,environmental constraints, anatomical variations with age, andinadequate training. Adult intubation performance and patientoutcomes for helicopter emergency medical services (EMS)providers have shown better results and improved survivalcompared with ground personnel.6,10 Pediatric prehospital in-tubation in this select group of providers, however, has beenunderreported. We report a consecutive series of pediatric in-tubations performed within an 89-rotorcraft, multistate trans-port system (Air-Evac EMS, Ltd) to characterize methods,success rates, and rescue techniques when intubation is per-formed by flight paramedics and nurses, using rapid sequenceintubation (RSI) airway management protocols.

METHODS

Study DesignThis is a retrospective analysis of consecutive intubations

performed by flight paramedics and nurses. Institutional reviewboard approval was obtained both at the University of IllinoisYPeoria and at Brigham and Women’s Hospital (Harvard MedicalSchool) before analysis. Data analysis followed conventionsestablished for the National Emergency Airway Registry.

SettingIntubations were performed by personnel from a large air-

medical transport company (Air-Evac EMS), based in WestPlains, Mo. At the time of data collection, the company oper-ated 89 long-range (206L) helicopters out of 85 air-medicalbases throughout the central part of the United States (Fig. 1).Air-Evac transports to more than 1000 hospitals and recordsan average of 26,000 flights per year including both interfacil-ity transfers and on-scene flights. Most crews operate fromstations in rural settings and are not based out of urban oracademic medical centers. All providers underwent quarterlytraining consisting of seminars on airway assessment, diffi-cult airway management, and RSI under the instruction of re-gional medical directors. In addition, case-based skills sessions,utilizing neonatal and pediatric METI ECS simulators, wererequired that focused on intubation technique and difficult air-way management. In addition, extraglottic device (EGD) andneedle cricothyrotomy techniques were practiced every 3 months.Paramedics and flight nurses had an average of 12 years ofexperience and performed more than 25 airway procedures

ORIGINAL ARTICLE

Pediatric Emergency Care & Volume 29, Number 9, September 2013 www.pec-online.com 963

From the *Department of Emergency Medicine, Brigham and Women’sHospital; †Harvard-Affiliated Emergency Medicine Residency;‡Departmentof Emergency Medicine, University of Massachusetts, Worcester; §Division ofEmergencyMedicine, Harvard Medical School, Boston, MA; and ||Departmentof Emergency Medicine, University of Illinois, Peoria, IL.Disclosure: Dr Cox is an employee of Air-Evac EMS, Inc. The other

authors declare no conflict of interest.Reprints: William Wallace Tollefsen, MD, 75 Francis St, NH-236A,

Boston, MA 02115 (e-mail: [email protected]).This study was supported by a research grant from Air-Evac EMS, Inc.Copyright * 2013 by Lippincott Williams & WilkinsISSN: 0749-5161

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

annually through a combination of field and simulated intu-bations. Pediatric airway management was guided by standardintubation protocols that were reviewed and approved, annually,by the senior medical director. Indications for prehospital pe-diatric intubation included oxygenation or ventilation failure,inadequate airway protection, and predicted airway deteriora-tion before or during transport. Protocols outlined the use ofpretreatment drugs, induction agents, and neuromuscular block-ers for RSI, sedation-facilitated intubation, and algorithms forcrash and failed airway management. Accepted weight-baseddrug doses were used during airway management.

Selection of ParticipantsAll pediatric patients younger than 15 years who un-

derwent at least 1 airway maneuver from January 1, 2007, toDecember 31, 2009, were included in our analysis.

Methods of MeasurementEach encounter was categorized as either a medical or

trauma intubation based on the clinical and scene informa-tion. After an assessment by flight personnel and indicationsfor intubation were met, standard airway management proto-cols were followed. A difficult airway assessment was done,whenever possible, by each operator before administration ofmedication, and if appropriate for neuromuscular blockers,RSI was performed. The operator evaluated mouth opening,cervical spine mobility, mandible and tongue size, and locationof the thyroid cartilage before airway intervention. This ap-proach has been used successfully to predict difficult direct

laryngoscopy in emergency department patients.11 OrotrachealRSI was performed by direct laryngoscopy if the airway wasnot predicted to be difficult. An EGD (Combitube, Covidien,Mansfield, MA, laryngeal mask airway [LMA], or laryngealtube) was used as the initial airway maneuver if the patientwas thought to be too difficult to safely receive neuromuscu-lar blockade. Extraglottic devices placed as the first plannedmethod of airway control occurred with sedation only. Rare,in-flight cardiopulmonary arrests with a crash airway were man-aged with immediate direct laryngoscopy, without RSI medica-tions, followed by EGD placement if laryngoscopy failed. Afailed airway was defined in 2 ways: a failed intubation attempt incombination with persistent hypoxia (oxygen saturation G90%)despite maximal supplemental oxygen and assisted ventilations or3 failed intubation attempts by the flight nurse or paramedic.12

Failed airways were managed with either an EGD (LMA, laryn-geal tube, or Combitube), continued bag-mask ventilation, orsurgical airway if the patient could not be intubated or ventilatedby other means. Malleable stylets were used routinely. Video la-ryngoscopes were not available. The operator completed a con-temporaneous electronic flight record and standardized intubationreport following each intubation. Procedural entries for intubationhad a demand function on the electronic flight record and couldnot be skipped. Recorded variables included patient age, sex, es-timated weight, flight classification, protocol and drugs used,initial airway management maneuver, number of intubation at-tempts, intubation success, and use of rescue devices. An intu-bation attempt was defined as insertion of any laryngoscope bladewith passage of an endotracheal tube beyond the patient’s lips.

FIGURE 1. Coverage May for Air-Evac EMS, Inc.

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Confirmation of endotracheal tube placement was done by aus-cultation and colorimetric end-tidal CO2 detection. Successfulendotracheal intubation was defined by tube passage, result-ing in chest rise and color change on a qualitative end-tidal CO2

detector. Vital signs were noted to be ‘‘stable’’ or ‘‘unstable’’ bothbefore and after intubation, but specific values were not recordedin the registry. Intubation reports were monitored for complete-ness by each regional medical director with a reporting compli-ance of 100%.

Data Collection and ProcessingDuring or immediately after each flight, operators re-

corded all intubation details onto a structured data form. Datawere reviewed for completeness and entered by the medicaldirector and nurse educator into the company’s main database(SQL database; Microsoft Access, Redmond, Wash). Data werethen imported into a spreadsheet (Microsoft Excel, Redmond,Wash) for analysis. Structured queries were performed to re-trieve relevant data with regard to intubation method, success,attempts, rescue techniques, and the use of surgical airways.

Primary Data AnalysisWe present descriptive data and Fisher exact and W

2 testsfor binary comparisons, with P G 0.05 considered significant.We performed all analyses with SAS 9.12 (SAS Institute,Cary, NC).

RESULTSDuring the 3-year study period, 4871 intubations were

performed within the Air-Evac system including 260 pediatricintubations. Of pediatric intubations, 88 (33.8%) were per-formed for medical indications, and 172 (66.2%) were fortrauma. The most common indications for pediatric intubation

were head injury (n = 64) and seizure (n = 26), respectively.The mean patient age was 7.33 years. One hundred three(39.6%) were female, and 157 (60.4%) were male.

Figure 2 depicts methods chosen, failed intubation en-counters, and the rescue methods used; 98.8% (n = 257) ofthe 260 patients underwent an orotracheal intubation attemptas the first method, all using RSI. Intubation was successful onfirst attempt 78.6% (n = 202) of the time and was ultimatelysuccessful in 95.7% (n = 246) of patients. Of successful in-tubations, 95.9% (n = 236) were completed in 2 or fewer at-tempts (Fig. 3). There was no difference in intubation successbetween medical and trauma patients (98% vs 95%, Fisher ex-act test P = 0.3412). In addition, there was no difference in in-tubation success between patients in age groups 0 to 2, 3 to 7,and 8 to 14 years (W2 = 0.26, P = 0.88). Age-stratified successrates are presented in Table 1. Three patients (1.1%) weremanaged primarily with an EGD as the first method chosenwithout an antecedent intubation attempt; all were successfully

FIGURE 2. Breakdown of airway management encounters.

FIGURE 3. Success rate per attempt number.

Pediatric Emergency Care & Volume 29, Number 9, September 2013 Pediatric Air Transport Intubations

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oxygenated. Eleven patients were not successfully intubated.Of these, 7 were successfully managed with an LMA and 2with a Combitube. Rescue cricothyrotomy was performed in2 patients, aged 2 (needle cricothyrotomy) and 14 years (open[surgical] cricothyrotomy). Both were successful. There wereno reports of a patient death due to a failed airway.

DISCUSSIONOut-of-hospital airway management remains a necessary

lifesaving procedure for critically ill and injured children, yetheterogeneous results regarding prehospital intubations, thepaucity of prehospital pediatric intubation literature, and thefeasibility of prolonged bag-and-mask ventilation in lieu oftracheal intubation leave the extent of prehospital pediatric air-way management up for debate.9 Tracheal intubation is a high-risk procedure that requires specialized training, practice,knowledge of airway anatomy, human physiology, pharmacol-ogy, and plans for rescue should intubation fail. Even garden-variety intubations represent a high-risk situation for everypatient, especially when neuromuscular blockade is used. Air-medical teams often take care of the most severely compro-mised pediatric patients for whom expert airway managementmay have a direct impact on outcome.7Y9,13,14 For our group ofoperators, prehospital pediatric airway management is most oftenaccomplished with tracheal intubation by direct laryngoscopyusing RSI, showing acceptable first-pass success rates and highultimate success rates. Air-medical intubation success rates instudies including both adult and pediatric patients, using RSIprotocols, have demonstrated intubation success rates as high as95%.15Y20 Our study showing 95.7% success confirms thesefindings and suggests it extends to pediatric populations. Perfor-mance may be typical of other air-medical programs with sim-ilar operator characteristics.

Significant anatomic differences exists among patientsyounger than 3 years. This can make intubation more chal-lenging for neonates and very young children. Subgroup anal-ysis of children aged 0 to 2, 3 to 7, and 8 to 14 years showedsimilar intubation success rates. Although our number of failedintubations is small, rescue methods, including placement ofEGDs and surgical airway techniques, were successful 100%of the time.

Early investigations of out-of-hospital pediatric intubationsuccess by ground providers have shown varying results, butas many as 43% of prehospital intubations may be unsuccess-ful.21 This inconsistency has many contributing factors but hasbeen linked, in part, to minimal airway management require-ments for paramedic certification and skill degradation becauseof infrequent field intubations.22,23 Procedural accomplish-ment is associated with repetition, and paramedics in high-volume settings or those with greater access to simulation oroperating room experience have shown higher rates of intu-bation success.24 The baseline skill set of intubators in ourstudy was high. Air-Evac provides an extensive airway training

program for new employees and maintains skills through regulartraining sessions, all with strict oversight by regional medical di-rectors. In our study group, the average paramedic and flightnurse had more airway management experience than what istypically seen for ground paramedics.23 Like other rarely per-formed, high-risk procedures, experience and simulation train-ing are likely going to play a prominent role in maintainingskills.25Y30 Our findings suggest that prehospital providers, whenprovided adequate intubation experience supplemented by simu-lation training, are highly skilled and successful with emergencyairway management in pediatric populations. This has impli-cations for all EMS companies as they evaluate ongoing pa-ramedic education and skills maintenance.

Eleven patients (4.2%) were not intubated and requiredrescue airway maneuvers. Although this number is small, anyfailed airway is concerning, given the possibility of prolongedhypoxia. In our study, all patients except 2 had successful res-cue with an EGD, most commonly an LMA. Surgical airwayswere performed successfully on the remaining 2 patients. Thesefindings indicate that backup management plans can be en-acted efficiently and successfully in our study group. Intro-duction of video laryngoscopy for pediatric intubation in thissystem might further help to reduce the failure rate to zero,the desired level.

LIMITATIONSOur study has some important limitations. First, these in-

tubations were performed by advanced paramedics and flightnurses within a high-volume air-transport company, and ourresults represent what operators with a similar training and in-tubation volume might achieve. These results may not be gen-eralizable to traditional paramedics working in other settingsor with lower annual intubation volume. Second, self-reporteddata have intrinsic limitations, and underreporting of poorlyperformed intubations including those with multiple failed at-tempts and adverse events is possible. Close compliance mon-itoring by regional medical directors and mandatory reportingfields for intubation in the electronic flight record limits thepossibility of selective reporting. The structured data form wasoriginally designed for internal, administrative purposes andwas not created with a developed research protocol in mind.This has introduced nonstandard definitions and variables intoour data pool and has limited our ability to perform certainanalyses. For future studies, operational definitions can be clar-ified during prospective collection. First, the definition usedfor tracheal intubation attempt required insertion of a trachealtube while the most widely used definition of intubation at-tempt simply requires insertion of the laryngoscope blade be-yond the teeth. Therefore, it is impossible to tell whether thepatients we reported as being primarily managed with an EGDas the first airway maneuver actually had a direct laryngo-scopic attempt first. This would bias our results toward betterfirst-pass intubation success. However, because that numberwas small (n = 3), success outcomes would have remained vir-tually unchanged. In addition, many data points that would haveadded and additional level of understanding were not collected.Vital signs surrounding intubation were noted to be ‘‘stable’’or ‘‘not stable,’’ but specific values were not recorded. We alsocannot make comparisons stratified by the medications used.With the exception of pretreatment agents, medications usedduring intubation were documented in the registry as drugclasses instead of specific agents. In other words, if RSI wasperformed, then succinylcholine or rocuronium could have beenused at standard doses and that would have been an acceptable

TABLE 1. Success by Age Group

AgeSuccessYes

SuccessNo

SuccessRate Total

0Y2 y 53 2 96.4% 553Y7 y 78 3 96.3% 818Y14 y 115 6 95.0% 121Total 246 11 95.7% 257




entry for ‘‘paralytic used’’ without knowing which agent wasadministered. Finally, prehospital airway studies often use des-tination tube confirmation as a measure of validating successfultracheal intubation. This was not recorded, and therefore anoverestimation of intubation success within our sample ispossible.31Y34 All tubes, however, were verified with end-tidalCO2 detection, in addition to auscultation and observation ofchest rise. In addition, waveform capnography was a routinepart of the postintubation care during transport, making thechance of an unrecognized misplaced tube very low. There wereno reports of patient death due to a failed airway. Patientsintubated by Air-Evac personnel but not flown because of in-stability or ongoing cardiopulmonary resuscitation in the fieldwere not included in our analysis because a transport flight re-cord was not generated for these encounters. Certainly, thispopulation had poor outcomes, and some may have died as aresult of failed airway management. Although this is possible,the likelihood that this number is large enough to have ameaningful impact on overall success is small. Nevertheless,this biases our findings toward better performance.

This group of advanced-level providers underwent ad-vanced simulation airway training multiple times per year aspart of routine competency checks, and the effect this extratraining has on final performance above that obtained from real-life experience is difficult to gauge. Finally, patients were notfollowed longitudinally in the hospital, and final functional orsurvival outcomes were not recorded. How our results translateto patient survival and neurologic function requires furtherstudy.

CONCLUSIONSIn this high-volume air-transport agency, skilled prehos-

pital providers, using RSI protocols, exhibited high pediatricintubation success rates, modest first-pass success rates, andsuccessful application of rescue methods including use ofEGDs and surgical techniques. These data may be used to bet-ter define performance standards for air-medical providers per-forming pediatric tracheal intubation.

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Two Hundred Sixty Pediatric Emergency Airway Encounters ......Pediatric airway management was guided...

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