Prehosp Emerg Care. 2020 May-Jun;24(3):411-420. doi: 10.3109/10903127.2015.1102993. Epub 2016 Nov 21.
Airway management is a common, important intervention for critically ill patients in the United States. A key element of prehospital airway management is endotracheal intubation (ETI). Prehospital ETI success rates have been shown to be as low as 77% compared to in-hospital rates of 95%. Given these rates, the use of backup airway devices is a necessary precaution for patient safety. The extent to which paramedics integrate backup airway use into their airway algorithm is unknown. The purpose of this study was to assess paramedic comprehensive airway management practices during a difficult airway simulation through which paramedics were obligated to consider alternatives to ETI. This was an observational study of airway management skills in active paramedics ( = 198). A difficult airway simulation was conducted in a mobile simulation laboratory; a Type 3 ambulance with four video cameras including an endotracheal view to capture airway management. Recordings of paramedic performance were assessed using a 110-item checklist covering four key areas: 1) placement of an endotracheal tube; 2) application of backup airway following failed ETI; 3) ventilation of the patient; and 4) achievement of airway safety and quality measures. Paramedics were highly trained with 12 years (IQR: 4-20) of advanced life support experience and a median of 40 prehospital intubations over their careers (IQR: 15-100). In this difficult airway setting, first pass ETI success rate was 55.6%. However, paramedics were challenged with airway management following a failed ETI. Only 9% of providers were prepared with a clear backup plan. Sixty-three percent of the paramedics successfully placed a backup airway within 3 attempts. During the simulation, only 14% properly ventilated at a rate of 10-12 breaths/min. Ventilations were maintained without interruptions (>30 sec) in 22% of simulations. In a difficult airway management scenario designed for low ETI success rates, even experienced paramedics were challenged with comprehensive airway management. This was exemplified by difficulties with the use of backup airway devices. Future work needs to be directed at identifying the key determinants for airway management success and the development of interventions to improve success with the use of a comprehensive airway management plan.
气道管理是美国危重症患者常见且重要的干预措施。院前气道管理的一个关键要素是气管插管（ETI）。与院内 95%的成功率相比，院前 ETI 的成功率低至 77%。鉴于这些成功率，使用备用气道设备是保障患者安全的必要预防措施。急救人员将备用气道设备的使用纳入其气道管理方案的程度尚不清楚。本研究的目的是评估急救人员在困难气道模拟中综合气道管理实践，在此过程中，急救人员必须考虑 ETI 的替代方案。这是一项关于急救人员气道管理技能的观察性研究（n=198）。在移动模拟实验室中进行了困难气道模拟；一辆配备四个摄像头的 3 型救护车，其中一个摄像头可以观察气管内插管以捕获气道管理情况。使用涵盖四个关键领域的 110 项检查表评估急救人员的表现：1）气管内插管的放置；2）ETI 失败后应用备用气道；3）患者通气；4）实现气道安全和质量措施。急救人员接受了高度培训，具有 12 年（IQR：4-20）的高级生命支持经验，在其职业生涯中中位数为 40 次院前插管（IQR：15-100）。在这种困难的气道环境中，首次 ETI 成功率为 55.6%。然而，急救人员在 ETI 失败后面临气道管理的挑战。只有 9%的提供者有明确的备用计划。63%的急救人员在 3 次尝试内成功放置备用气道。在模拟过程中，只有 14%的人以 10-12 次/分钟的速度正确通气。在 22%的模拟中，通气没有中断（>30 秒）。在为低 ETI 成功率设计的困难气道管理场景中，即使是经验丰富的急救人员也面临全面气道管理的挑战。这表现在备用气道设备使用困难。未来的工作需要确定气道管理成功的关键决定因素，并制定干预措施，以改善使用全面气道管理计划的成功率。
