Paramedic Intubation of Pediatric Patients

My 2010 research/opinion paper.

For more than 20 years, the “gold standard” for definitive pre-hospital paramedic level airway management in both adult and pediatric patients has been endotracheal intubation (ETI). ETI can best be described as the process of inserting a lighted laryngoscope blade into the oropharynx to displace the mandible and tongue in order to view the glottis while passing a hollow plastic tube through the vocal cords into the trachea to allow for direct ventilation. In several non scientific polls where paramedics are surveyed, endotracheal intubation has been identified as the one critical skill that differentiates paramedics from EMT-Basic and Intermediate level providers, even more so than manual defibrillation and IV drug therapy. Paramedics have often called ETI, “the skill that makes us medics.” However, there are several published studies that question the amount of training that both paramedic students and credentialed paramedics receive and the lack of ability of students to demonstrate baseline competency in ETI. Also questioned in numerous studies is the efficacy of pre-hospital ETI by paramedics in both adult and pediatric patients and the relationship of pre-hospital ETI to patient outcome. This paper will examine paramedic level intubation education and it’s associated competency baselines, programs of continuing education for field providers and the recommendations of health care providers in relation to pre-hospital ETI in order to answer the question, “Should paramedics still be preforming pre-hospital pediatric intubation?”

ETI Baseline Competency
Paramedic students learn the techniques of advanced airway management primarily in the classroom by performing practice intubation on airway manikins. After demonstrating competency with manikins, the USDOT 1998 National Standard Curriculum for Paramedic Education recommends that students perform at least five human intubation procedures, either in a hospital operating room (OR) or in the field. It is widely recognized that this OR experience is a fundamental part of paramedic training as it pertains to ETI. However, a study presented at a meeting of the National Association of EMS Physicians in 2009, which surveyed paramedic education program directors that utilized OR time for student ETI practice, showed that due to limitations in OR access for paramedic students through competition for ETI practice by other allied health students, coupled with the usage of alternative airway adjuncts in the OR, such as the LMA, meant that in several programs, students were unable to meet even the baseline recommendation of at least 5 live intubations, which is far below the requirements for other health care professionals, despite the importance of intubation in airway management. As illustrated in a 2009 study from Harborview Medical Center in Seattle, five ETI attempts is far too to few even approach first pass ETI competency. The Harborview study illustrated that over a period a of three years, as 57 paramedic students first pass ETI attempts were tracked over 576 patients, “Increased ETI success rates were associated with increasing clinical exposure.” In fact, an additional study measuring competency of ETI skills of respiratory therapy students, paramedic students and medical students with no prior live ETI experience, conducted in Canada in 2003, showed that the competency score for an “uncomplicated” ETI in a controlled, well lighted environment, such as the ED or OR, only reached 80% after a mean of 35 laryngoscopic intubations, even after the student performed 20 or more intubations on training manikins. In this case, competency was measured by successful placement of the ET tube on the first or second attempt, without assistance from the anesthesiologist that was monitoring the student’s progress. Obviously, student expertise in managing more difficult airway cases would require many more live ETI attempts before baseline competency could be established. A similar study, published in Anesthesiology in 2003 statistically showed that a 90% chance of a “good” intubation would require a minimum of 47 prior student intubations, and proposed that the standard manikin training was insufficient to prepare students for actual live intubations. These studies illustrate a simple concept that makes sense. “The more you do, the better you get it.” It should be noted that the vast majority of intubation opportunities afforded to paramedic students are for adult patients in the OR, and the above mentioned studies all focus on adult ETI with no mention made of pediatric intubation skills or competency baselines.

Pediatric Intubation Overview
The pediatric airway has many anatomical differences from the adult airway. Some significant features of the pediatric airway include a larger, more floppy epiglottis, a larger tongue and smaller mandible, a smaller, shorter and more narrow trachea and funnel shaped anatomy inferior to the vocal cords. In addition, infants and small children have a larger, rounder occiput which causes the neck of a supine child to be in a flexed position. Fortunately, aside from the anatomical differences, pediatric patients rarely present with a “difficult airway” as scored by the “LEMON” method, however the lack of opportunity for paramedic students to practice pediatric intubation may very well result that the first time a pediatric ETI is attempted by a medic, it is in the field during an emergency call. In that instance, a chaotic scene, significant major trauma, hysterical parents and bystanders and the emotional impact of treating a child, coupled with a lack of experience in the invasive management of a pediatric airway may result in disaster when a paramedic must intubate a pediatric patient. In 2000, Gausche, et al, conducted an alternating day study of Pediatric Intubation vs Bag Valve Mask (BVM) ventilation of patients in Los Angeles and Orange Counties in California. This much contested study claims that there was no increase in positive outcome when pediatric patients were intubated compared to being simply ventilated via BVM. In fact, the study shows patients who received ETI were subject to prolonged on scene times and suffered frequent complications, and in no way did pre-hospital ETI improve survival or neurological outcome. Following this study, both Los Angeles and Orange Counties have disallowed paramedic intubation of pediatric patients and other locales are following suit. A 2009 newspaper article in the Riverside California Press Enterprise noted that Riverside County paramedics had pediatric intubation removed from their scope of practice by medical director Dr. Humberto Ochoa, who directly cited the 10 year old Gausche study when he claimed that BVM ventilation was “…a much less dangerous procedure… we thought we would probably do better by going back to the basics.” However, when asked about specific problems related to paramedic intubation of pediatric patients, Ochoa declined to comment.

Pediatric ETI in Practice
While BVM ventilation of many patients in respiratory distress or arrest may well be an acceptable alternative to ETI, as noted in the Gausche study, there are instances where pediatric ETI is the preferred method of airway control. Cases such as inhalation injury, anaphylaxis and restrictive airway diseases, which may require high pressure ventilation, can only be managed with ETI. It is imperative that paramedics be well educated and prepared to definitively manage the pediatric airway in these cases. In 1993, a study of licensed EMS agencies in Oklahoma showed that only 4% of the EMS responses were for pediatric emergencies. Also, many of these agencies were reluctant to allow their paramedics to practice advanced pediatric resuscitation skills, disallowing ETI in patients under the age of 12, and only 57% of the agencies that responded to the survey covered pediatric topics in continuing education. A study, conducted at Michigan State University in 1998, examined the frequency of advanced EMS field interventions in children and showed that opportunity to perform advanced skills in the field was rare and of the 535 pediatric EMS runs audited, only 19.3% had advanced procedures (i.e.: venous access) performed in the field and no children were intubated. It is obvious from these studies that a relatively small number of pediatric calls that require ETI, coupled with poor education and the reluctance of some agencies to allow paramedics to preform pediatric skills could leave EMS providers ill prepared to efficaciously manage the critical pediatric airway. With these rare field opportunities, it is logical to propose that strong initial training, coupled with continuing education is the key to success in pediatric ETI. There are several studies that show significant increases in paramedic skill competency following the completion of a Pediatric Advanced Life Support (PALS) course. In one 2009 retrospective study that examined the efficacy of PALS Training in emergency medical service providers, showed the that success rate of pediatric intubation by PALS trained paramedics who had performed ETI in the pediatric OR under the eye of a pediatric anesthesiologist climbed to 85% compared to just 48% for non PALS rescuers over a three year period.

Summation and Conclusions
Even though paramedic ETI has been the gold standard of advanced airway management for over 20 years, a hard look should be taken at the number of intubations that paramedic students are required to perform before being judged competent at the skill. Several studies have shown that the recommendation of 5 live OR intubations are far to few to develop a baseline competency in adult intubation. As for pediatric intubation skills, the only training offered in most programs is on a manikin and there are very few opportunities for paramedic students to perform any live pediatric intubations. Prior to being granted the ability to intubate infants and children in the field, I feel that paramedics should perform a sufficient number of live adult ETI opportunities to be judged baseline competent; scored as placement success on the 1st or 2nd attempt without asking for assistance, 80% of the time. After that baseline competency has been established, paramedic students should be required to manage pediatric airways in the OR, under the supervision of a pediatric anesthesiologist until baseline competency with the pediatric airway has been established. Until that point, student paramedics may be allowed practice in the field, cleared for adult intubation only. In most cases, this will prove to be effective, as was noted in the Gausche study, for most pediatric cases, the airway can be managed adequately with a BVM and there is no correlation to positive neurological outcome or survivability between pediatric patients who’s airway was adequately managed with a BVM versus those patients intubated in the field.
In summation, it is the opinion of the author, that pediatric ETI not be considered a basic paramedic skill, instead it should be an additional advanced skill that is cleared by the medical director only after baseline adult ETI competency is established, if it is not done in the initial paramedic education program. In addition, more stringent continuing education standards should be established, with paramedics in their first re-certification cycle required to perform adult and/or pediatric ETI in the OR once per quarter to demonstrate that they maintain their baseline competency. After the first re-certification cycle, paramedics should visit the OR twice yearly to demonstrate competency. With competition for OR time fierce and airway adjuncts such as the LMA replacing ETI in many surgical procedures, these goals may be out of reach for many paramedic programs. In any case, it is clear that paramedic educators must explore different options for pediatric airway training, aside from the traditional OR and ED rotations. Options such as performing presurgical intubation at a veterinarian’s clinic or the intubation of freshly euthanized cats may be the outside the box thinking that will help to assure that new paramedic students are not only well educated in pediatric airway management but are competent at performing the skills.

Works Cited
Anshuman, Sharma. “Pediatric Airway Workshop.” Pediatric Airway Workshop. St. Louis Children’s     Hospital, Web. 10 May 2010.

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Burge, Sarah. “Riverside County paramedics no longer can use breathing tubes for children.” The Press Enterprise [Riverside] 3 June 2009: PE.com. Web. 23 May 2010.
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