In “Intubation for Cardiac Arrest Patients,” author Samuel M. Galvagno Jr., DO, PhD, identifies several reasons why intubation has not been shown to positively impact outcomes for cardiac arrest patients.
First, intubation during cardiac arrest is not always straightforward, and in at least one study, 30% of patients required more than one attempt.(1)
Second, the learning curve to attain competence is steep—one study suggests up to 60 intubations are required to become proficient—and in some systems, EMS providers do not have opportunities maintain this skill.(2) As Nable et al write, “maintaining proficiency in endotracheal intubation is a significant barrier for many prehospital providers.”(3) In Wang et al, intubation success by medics was only 78%.(1)
Third, intubation is followed by positive pressure ventilation (PPV), and PPV has been shown to decrease preload, lower cardiac output, and negatively impact the effectiveness of chest compressions.(3)
Fourth, intubation may require interruption of chest compressions, and this has clearly been linked with worse outcomes.(4) For the abovementioned reasons, in some countries, such as the U.K., a case has been made for abandoning intubation altogether in cardiac arrest.(5)
References
1. Wang HE, Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation? AcadEmerg Med. 2006;13:373–377.
2. West MR, Jonas MM, Adams AP, et al. A new tracheal tube for difficult intubation. Br J Anaesth. 1996;76:673–679.
3. Nable JV, Lawner BJ, Stephens CT. Airway management in cardiac arrest. Emerg Med Clin N Am. 2012;30:77–90.
4. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335–340.
5. Deakin CD, Clarke T, Nolan J. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group. Emerg Med J. 2008;27:226–233.
