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Esophageal Gastric Tube Airway vs Endotracheal Tube in Prehospital Cardiopulmonary Arrest Chest 1986

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Irvin Goldenberg Esophageal Gastric Tube Airway vs Endotracheal Tube in Prehospital Cardiopulmonary
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  Esophageal Gastric Tube Airway vs Endotracheal Tube in Prehospital Cardiopulmonary Arrest lruin E Coldenberg M.D.; Brian C. Campion M.D.; Constance M Siebold R.N.;]ohn W McBride M.D.; and Linda Long M.D. We evaluated the efficacy of the esophageal airway (EA) by prospectively randomizing 175 prehospital cardiopulmo- nary arrest patients to receive either an esophageal gastric tube airway (EGTA) or an endotracheal tube (ET). If attempts with the initid airway failed, the alternate airway was attempted. The cost of training paramedics in EA use was considerably less than the ET ( 80 vs 1,000). Survival to the emergency room, to hospitalization and to discharge in ET and EGTA pups were 64.4 percent, 25.6 percent, ll.1 percent, and 54.1 percent, 27.1 percent, B.9 percent, he optimal airway for respiratory management of a Tpatient with cardiopulmonary arrest is a well- placed endotracheal tube (ET). However, the place- ment of an ET requires a certain level of skill with training and recertification requiring substantial time and resources. Therefore, alternative methods for ventilation have been sought. The esophageal airway, ie both the esophageal obturator airway (EOA) and the esophageal gastric tube airway (EGTA), were devel- oped s such alternatives to the ET. Despite the esophageal airway s acceptance s a useful airway adjunct by the National Conference on Cardiopulmo- nary Resuscitation and Emergency Cardiac Care in 1973 and 1979,0 the efficacy of this airway remains contro~ersial.~ o evaluate the efficacy of the esophageal airway (EA), we performed a study compar- ing morbidity and mortality in patients prospectively randomized to receive either the EGTA or the ET in prehospital cardiopulmonary arrest. We also compared these patients to a group of unrandomized patients who were resuscitated by paramedics trained only in esophageal airway intubation. METHODS St Popuhtion During a myear period, 175 patients with out-of-hospital *From the Section of Cardiolo and Office of Emergency Medical Services, St. Paul-Ramse Mgcal~enter, t. Paul and University of Minnesota Medical ~Xool, Minneapolis. This work was supported in part by a grant from the Medical Education and Research Foundation of St. Paul-Ramsey Medical Center and Ramse Clinic, St. Paul, MN. Manuscript receivedr ~ugust 6; revision accepted anuary 28. Reprint requests: Dr ong St. Paul-Ramey Me Center 640 Jackson Street, St. Poul5 901 d d respectively-differences not statistically significant. The incidence of neurologic residual (ET 50 percent, EGTA 36.4 percent) and congestive heart failure (ET 40 percent, EGTA 45.5 percent) in surviving ET and EGTA patients did not differ (NS). An additional onsecutive patients with only the opportunity to receive an EA were also evaluated and did not differ in mortality, neurologic residual, or congestive heart failure from ET patients. We conclude that the EA is a satisfactory alternative to the ET for short-term prehospital use in cardiopulmonary arrest patients. cardiopulmonary arrest were prospectively randomized at the time of paramedic arrival at the scene to receive the ET (group 1) or the EGTA (group 2) for initial airway management. On paramedic arrival, a card was drawn. The writing on this card determined whether the patient's initial airway attempt was to be an EGTA or an ET. The random order of these cards was deterniined from a table of random numbers. If tw attempts with the initial airway failed to adequately ventilate the patient, the alternative airway was at tempted. Inclusion criteria required that the patient's initf l airway management with an esophageal airway or an endotracheal tube be done by paramedics participating in the study and that any patient entered into the study be at least five feet tall. The 35 paramedics participating in this part of the study were trained in both ET and EGTA insertion. All patients were treated by paramedics in the St. Paul, Minnesota Paramedic Program. During the same period, an additional 25 consecutive patients with out-of-hospital cardiopulmonary arrest who were not ran- domized but who had an EOA attempted by paramedics trained only in esophageal airway placement were evaluated (group 3 . These patients were ventilated by an esophageal airway, or if this failed, by an oral airway. These additional 25 atients were compared to group 1 patients to see if they differed in morbidity or mortality. Esophageal iwy The esophageal airway and its insertion have been described in detail elsewhere.LPg Proofder o Care The St. Paul Paramedic Program has 25 paramedics. Thirty-five of these paramedics were trained in both endotracheal tube and esophageal airway intubation. The remainder were trained only in esophageal airway intubation. Endotracheal intubation training consisting of U hours of didactic work, mannequin practice, and 12 to 16 intubations in the operating room cost approximately 1,000 per paramedic. Completion of training was based on an evaluation for proficiency by the Department of Anesthesiology prior to using the ET in the field. Each paramedic was required to return to the operating room each year to demonstrate endotracheal intubation Downloaded From: http://journal.publications.chestnet.org/ by a University of Minnesota Libraries User on 01/02/2014  under supervision. The EGTA and EOA training, which consisted of three hours of didactic work and mannequin training, cost approx- imately 80 per paramedic. During management of all cardiac arrests, paramedics received orders through radio and telemetry contact with St Paul-Ramsey Medical Center physicians. The Medical Center serves as the medical control base station for Ramsey, Washington, and Dakota Counties. Cardiac arrests were treated according to American Heart Association Advanced Cardiac Life Support guidelines.' Data were obtained on all patients from special protocol study reports, routine paramedic run reports, emergency mom (ER) records, and hospital charts. The data collected included the following: population characteristics (age, sex, initiator of CPR, initial rhythm, time from arrest to initiation of CPR, ie downtime, time from arrest to paramedic arrival, time required for intubation, cause of arrest, preintubation vomiting, past medical history), hospital course (neurologic sequelae, incidence of congestive heart failure, incidence of aspiration pneumonia), survival data, ditficulties with airway establishment, airway complications, and in some patients, arterial blood gas levels (ABGs). The downtime was estimated by the bystander at the scene. It equalled the time between the onset of the cardiac arrest and the beginning of basic life support measures (CPR). The time to paramedic arrival equalled the time between the onset of the cardiac arrest and the time the paramedics arrived at the scene. Statistical analysis was performed using chi square tests, Fischer's exact probability tests, and Student's t-tests. Statistical analysis was performed (1) between the patients randomized to ET (group 1) and patients randomized to EGTA (group 2), and (2) between the patients randomized to ET (group 1 and the 115 consecutive patients who were not randomized but had the EOA attempted (group 3). The data in this paper are presented by intent to treat groups (groups 1 o 3). but incorrect randomization occurred in 17.1 percent of the patients. Therefore, statistical analysis was also performed between the following groups: (3) Correctly randomized ET patients vs correctly randomized EGTA patients. 4) Randomized patients receiving an ET as final airway vs ran- domized patients receiving an EGTA as final airway. (5) Correctly randomized patients vs incorrectly randomized pa- tients. (6) Correctly randomized ET patients vs group 3 patients. (7) Randomized patients receiving ET as final airway vs group 3 patients. The data presented in this paper reflect intent to treat unless otherwise stated. However, whenever significant results were obtained by any of the above analyses, they are reported. One hundred seventy-five patients were ran- domized (Table 1 . Ninety were randomized to ET and 85 to EGTA. However, only 145 of these 175 patients were correctly randomized (81 to ET, 64 to EGTA). That is, 30 patients either &led to meet inclusion criteria or the randomized airway was not attempted in able 1 Croups nalyted Total ET EGTA Initially randomized 175 90 85 NS Correctly randomized 145 81 6 p<O.O% Incorrectly randomized 30 9 21 ~~0.025 Find airway 171 119 52 pC0.005 able ?--Reasons for Znccnmxt Radnnidh ET Incorrectly Randomized EOA by first responder before paramedic arrival: 2 month old patient-oral airway used: Mental erroflooked at card wrong: EGTA Incorrectly Randomized Paramedic decided to attempt ET despite pulling EGTA card because: Poor seal with face mask : Patient had Aspirated and needed suctioning : EOA placed by first responder before paramedic ar- rival: Mental errorn/looked at card wrong: Long downtime : More positive pressure 0, could be delivered through ET: Misunderstanding re: EGTA : There was a delay in starting the IV No EGTA on rig: their initial airway management (Table 2). More pa- tients were correctly randomized to the ET (p<O.025). One hundred seventy-one received either an ET (ll9 patients) or an EGTA (52 patients) as their final airway. Four patients received neither airway. More patients received an ET as their final airway (p<0.005). Comparability of the roups Table 3 lists the age, sex, downtime, time from arrest to paramedic arrival, and past medical history for group 1,2, and 3 patients. Age w s significantly higher in patients randomized to receive the EGTA compared to patients randomized to receive the ET (69 vs 64 years) (p<0.05). The other characteristics listed in this able Population harm Group 1 Group 2 Group 3 Number Sex: M F Age* Downtime? rime to paramedic arrivalt Past medical history Positive cardiac. Negative cardiac Unknown cardiac Noncardiacs ETOH DM COPD *Mean years standard deviation, p<0.05 group 1 vs group 2. mime in minutes, standard deviation (see text for definitions for determining times). $Includes history of congestive heart failure, myocardial infarction, hypertension, angina, pacemaker, coronary artery bypass surgery, positive history but unknown specific type. BETOH is alcoholism; DM, diabetes mellitus; COPD, chronic obstructive pulmonary disease. CHEST 9 1 JULY 11988 91 Downloaded From: http://journal.publications.chestnet.org/ by a University of Minnesota Libraries User on 01/02/2014  Table 4 Car~nunuay Arresi Charectcrbtics Table Morbidity in Haapidbd Patients Group 1 Group2 Group3 Number 90 85 125 Initiator of CPR Paramedic 57 52 71 Public 12 12 20 Emergency medical technician 18 13 27 Nurse 2 6 5 Physician 0 1 0 Police 1 1 1 Unknown 0 0 1 Initial rhythm Ventricular tachIFib* 50 45 66 ~rad~cardialblbcks 23 20 19 Asystole 16 14 29 Electromechanical dissociation 1 4 10 Unknown 0 2 1 Cause of arrest Cardiac 73 67 97, Rimary respiratory arrest 6 10 10 Other 9 7 7 Unknown 2 1 11 Reintubation vomiting 6 5 4 *Ventricular tachycardia/fibrillation includes only one patient with ventricular tachycardia in group 2. table were similar between patients randomized to ET or EGTA and between the patients randomized to ET and group 3 patients. Eble 4 lists the initiator of CPR, the initial rhythm, the cause of arrest, and the incidence of preintubation vomiting in these groups. There were no statistically significant differences in any of these characteristics between the patients randomized to ET and the patients randomized to EGTA. When the group 1 patients were compared to the group 3 patients, the frequency distribution of the initial rhythm w s differ- ent between the groups. The d rence w s almost entirely due to the high incidence of electromechani- cal dissociation in the group 3 patients. The incidence of ventricular fibrillation/ventricular tachycardia w s similar between these two groups. Group 1 and group 3 patients were otherwise similar. Arterial Blood as Levels The purpose of this study w s to determine if there w s a difference in morbidity or mortality in patients randomized to or receiving the ET or EGTA. The drawing of ABGs immediately after arrival to the ER Table Ad Blood as V ET EGTA PH 7.21 20.22 7.21 20.25 pot 121 127 149k 132 Pco, 51234 46 29 Hco, 1925 18k8 Xme to intubation* min) 5.97k3.86 6.002 1.26 Group 1 Group 2 Group3 Number 90 85 125 Hospitalized patients 23 23 34 Neurologic residual Initial event 16 10 20 Prior to death or discharge 17 14 20 Congestive heart failure 13 7 19 Aspiration pneumonia 5 8 N A *NA, data not obtained. was not an integral part of the study. However, 67 of the randomized patients and 31 of the group 3 patients had ABGs drawn soon after arrival in the ER. There was no statistically significant difference in the ABGs or in time elapsed from intubation to arterial sampling in patients receiving the endotracheal tube or esophageal airway (Table 5). Hospital Course Eble 6 lists the incidence of neurologic residual, congestive heart failure CHF), and aspiration pnsu- monia in hospitalized patients. The incidence of neu- rologic residual secondary to the initial cardiopulmo- nary arrest and the incidence of neurologic residhal secondary to any event after and including the initial event were similar between group 1 and group patients and between group 1 and group 3 patients. Analysis, however, between patients correctly ran- domized to ET and patients comctly randomized to EGTA showed a significmtly higher incidence of neurologic residual that could be attributed to the initial event in the ET patients 72.7 percent vs 31.6 percent) p<0.05). The incidence of congestive heart failure and aspiration pneumonia w s similar between the groups analyzed. When the incidence of neu- rologic residual and congestive heart failure were evaluated in surviving patients, there was no differ- ence between any of the groups analyzed (Eble 7). 'hble 8 shows survival by airway group. Survival to discharge w s U.1 percent in group patients, 12.9 percent in group 2 patients, and 12.0 percent in group 3 patients. Survival to the ER, to hospitalization, and to discharge w s not significantly different between the Table 7-Morbidity in Suroioing Ratienta Group 1 Group 2 Group3 Number 90 85 125 Patients surviving to discharge 10 11 15 Neurologic residual At discharge 5 4 3 Unknown 0 0 1 Congestive heart failure* 4 5 8 Unknown 0 0 1 *lime from arrest to airway placement. *During hospital course. ehospltel Cardbpulmonary nest Ooldenbsrp eta/) Downloaded From: http://journal.publications.chestnet.org/ by a University of Minnesota Libraries User on 01/02/2014  ¬†able 8 Sumival by Ainwy Group able 10-DiH with Ainwy Establishment Group 1 Group2 Group 3 N N Number 90 85 125 Survival to ER 58 64.4 46 54.1 78 62.4 Survivaltohospitalization 3 25.6 3 27.1 34 27.2 Survival to discharge 10 11.1 11 12.9 15 12.0 Unknown 1 1.2 groups analyzed. Table 9 shows no difference in survival to discharge in randomized patients by intent to treat groups, final airway received, and correctly randomized patients. Complications and Dificulties with imy Establishment When airway difficulties were evaluated, we found that the duration of the intubation procedure was similar for the patients receiving the ET, EGTA, and EOA, and that there w s approximately 90 percent successful airway placement with all tubes (Table 10). Table ll ists the complications in patients receioing the EGTA and ET. The incidence of complications w s similar in the two groups. Paramedic ssessment of irway dequacy More patients were judged to be adequately venti- lated with the ET than the EGTA when ventilation w s assessed by paramedics in the field (Table 10). Of the patients who had the ET attempted, 89 percent were judged to be adequately ventilated, while only 70 percent of the patients who had the EGTA attempted were judged to be adequately ventilated. If in the paramedics' opinion the patient w s being inade- quately ventilated with the EGTA, the protocol allowed placement of the ET. Therefore, most of the patients assessed by the paramedics to be inadequately ventilated with the EGTA subsequently received the ET. However, when paramedics who were trained only in esophageal airway intubation judged adequacy of ventilation in the field, they felt that 90 percent of the patients were adequately ventilated. Adequate ventilation is essential for a successful outcome in patients with cardiopulmonary arrest. At able 9 Sumival to Discharge Randomized Patients ET E GTA N Intent to treat 10 11.1 11 12.9 NS Final airway received 13 10.9 15.4 NS Correctly randomized patients 10 12.3 10 15.6 NS ET EGTA EOA Duration of intubation procedure* 19211 16212 21+19 Number of patients with tube attempted 132 125 Total number of patients with successll intubations 119(90.2 ) 71(92.2 ) llB(Q4.476) Number of patients with tube attempted adequately ventilated t 118(89.4 ) 54(70.1 ) 113(90.4 ) *Mean seconds) standard devikon. tAs assessed by paramedics in the field. present the optimal airway for respiratory manage- ment in an apneic patient is an ET. However, the place- ment of an ET requires a certain level of skill, the use of a laryngoscope, and frequent use or retraining to maintain proficiency. Because of the difficulties with learning and maintaining ET intubation skills, alter- native methods for ventilation were developed. In 1968, Don Michael et alu described a device that occluded the esophagus and simultaneously allowed ventilation of the lungs. This device with madifications is now known as the esophageal airway EOA and EGTA). Since its introduction, the esophageal airway has been used in approximately two million cardiopul- monary arrests. The advantages of the esophageal airway over the ET have been stated to be the relative ease and speed of insertion, shorter time required br raining and skill maintenance, lack of need for a laryngoscope, and its safer insertion in patients with cervical trauma. -CI.~ n addition, in our program, training is less costly for the esophageal airway. In communities where resources for training are limited, the esophageal airway would be an attractive alternative for short-term prehospital airway management i its efficacy could be docu- mented. To determine whether the EA is a suitable alter- native to the ET in the prehospital cardiopulmonary arrest patient, we evaluated these different airway managements in patients experiencing out-of-hospital cardiopulmonary arrest. Our results (Tables 6 through 9) showed that patients randomized to or receiving an EGTA or ET had similar survival rates, incidence of congestive heart failure, neurologic residual, and aspi- ration pneumonia. However, analysis between patients correctly randomized to the T and patients correctly randomized to the EGTA showed a significantly higher incidence of neurologic residual that occurred during the initial cardiopulmonary arrest in the ET patients. This finding would tend to favor the EA. However, because of our multiple statistical analyses and because this difference w s not present between patients ran- domized to or receiving the EGTA or ET, we do not HEST 9 1 JULY. 11986 93 Downloaded From: http://journal.publications.chestnet.org/ by a University of Minnesota Libraries User on 01/02/2014
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