Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drøbak, Norway.
Crit Care. 2012 Feb 11;16(1):R24. doi: 10.1186/cc11189.
Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.
We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.
From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P=0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P=0.047).
This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.
院前气道管理是一个备受争议的话题，但人们普遍认为，少数病情严重或受伤的患者需要紧急进行紧急气管插管（ETI）和通气。许多欧洲紧急医疗服务（EMS）系统提供医生来照顾这些患者，而其他系统则依赖护理人员（或很少情况下是护士）。ETI 成功率是衡量提供者和 EMS 系统成功的重要指标，也是患者安全的标志。
我们对 Medline 和 EMBASE 进行了系统搜索，以确定所有发表的报告成人患者院前 ETI 的原始英文文章。我们选择了所有报告 ETI 成功率的研究，并提取了尝试和成功 ETI 的数量、提供者类型、ETI 培训水平以及现场可用药物的信息。我们使用荟萃分析计算了总体成功率，并评估了 ETI 成功率与提供者类型之间的关系以及 ETI 成功率与现场可用药物类型之间的关系。
从最初检索到的 1070 项研究中，我们确定了符合选择标准的 58 项原始研究。非医务人员管理的服务中有 64%和医务人员管理的服务中有 54%报告了 ETI 成功率，但在 3 项非医务人员管理的研究中，成功率报告不完整。中位数成功率为 0.905（0.491，1.000）。在加权线性回归分析中，作为提供者的医生与更高的成功率显著相关，为 0.092（P=0.0345）。在非医务人员组中，药物辅助插管显著提高了成功率。所有医生都可以使用传统的快速序列诱导（RSI），与使用肌肉松弛剂或传统 RSI 的非医务人员相比，成功率仍有显著差异，分别为 0.991 和 0.955，（P=0.047）。
这项全面的荟萃分析表明，医生在整体上进行院前 ETI 时的失败率明显低于非医生。当非医生使用肌肉松弛剂或 RSI 时，这一发现仍然成立，这引发了重大的患者安全问题。在没有院前医生的情况下，应强烈考虑进行除 ETI 以外的基本或高级气道技术。
