Context
Endotracheal intubation (ETI) is widely used for airway management of
children in the out-of-hospital setting, despite a lack of controlled trials
demonstrating a positive effect on survival or neurological outcome.Objective
To compare the survival and neurological outcomes of pediatric patients
treated with bag-valve-mask ventilation (BVM) with those of patients treated
with BVM followed by ETI.Design
Controlled clinical trial, in which patients were assigned to interventions
by calendar day from March 15, 1994, through January 1, 1997.Setting
Two large, urban, rapid-transport emergency medical services (EMS) systems.Participants
A total of 830 consecutive patients aged 12 years or younger or estimated
to weigh less than 40 kg who required airway management; 820 were available
for follow-up.Interventions
Patients were assigned to receive either BVM (odd days; n = 410) or
BVM followed by ETI (even days; n = 420).Main Outcome Measures
Survival to hospital discharge and neurological status at discharge
from an acute care hospital compared by treatment group.Results
There was no significant difference in survival between the BVM group
(123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82;
95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good
neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95%
CI, 0.62-1.22).Conclusion
These results indicate that the addition of out-of-hospital ETI to a
paramedic scope of practice that already includes BVM did not improve survival
or neurological outcome of pediatric patients treated in an urban EMS system.
Figures in this Article
Although bag-valve-mask ventilation (BVM) and endotracheal intubation
(ETI) are both widely used in the out-of-hospital setting in caring for critically
ill or injured children, there has been no controlled study comparing the
outcomes of pediatric or adult patients treated with these 2 procedures. In
1 out-of-hospital study, BVM did compare favorably to non-ETI advanced airway
management techniques (pharyngeal tracheal lumen, laryngeal mask, and esophageal
tracheal combination esophageal-tracheal tube) among adults and children,
as measured by PO2 and PCO2 values on arrival in the
emergency department (ED), frequency of vomiting, and patient outcome.1
There have been a number of descriptive studies of ETI in the out-of-hospital
setting. Reported success rates of pediatric ETI vary from 50% to 100%, depending
on the patient's presenting illness or injury, the age of the patient, education
level of the health care provider, and use of neuromuscular blocking agents
to facilitate intubation.2- 10
Major complications of ETI, such as esophageal intubation, have been reported
in as little as 1.8% and as many as 17% of pediatric patients in the out-of-hospital
setting.7,10 One study reported
an overall complication rate of 22.6%, using succinylcholine to facilitate
intubation.10 Despite the fact that retrospective
studies comparing the survival of patients treated with BVM and ETI have generally
found no difference, some investigators have suggested that ETI may be beneficial
in certain patient subgroups, such as those with submersion injury and cardiopulmonary
arrest.4,6,11- 13
Moreover, despite limited comparative data for BVM and ETI, and the high complication
rates reported for pediatric ETI in the out-of-hospital setting, pediatric
ETI is taught in 97% of paramedic training schools and widely used by out-of-hospital
providers.14
This study compared the survival and neurological outcomes of pediatric
patients assigned to receive BVM with those of patients assigned to receive
ETI in the out-of-hospital setting.