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June 7, 2000

Out-of-Hospital Endotracheal Intubation of Children—Reply

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Contributing EditorIndividualAuthor

JAMA. 2000;283(21):2790-2792. doi:10.1001/jama.283.21.2787

In Reply: Although Dr Eckstein questions the adequacy of airway management training, we found no difference in the rate of "good chest rise" between BVM and ETI groups. Furthermore, pulse oximetry showed a median oxygen saturation of 97% to 98% in both BVM and ETI groups, which did not change during long transports. Eckstein also notes that California paramedics do not receive mandatory periodic skills testing. However, paramedics in this study were experienced in adult intubation, had substantial pediatric experience in a busy urban emergency medical services (EMS) system, were required to have 48 hours of continuing education training every 2 years, and were provided with pediatric airway continuing education opportunities throughout the study.1,2

We believe that our observed rate of successful ETI (57%) was lower than that reported in some other studies not because of a difference in the true rate of successful performance, but because of our stringent definition of intubation "attempt" and a relatively young pediatric population.3,4 Review of EMS documentation alone (as in some previous studies) would have greatly underestimated the true number of ETI attempts, falsely elevating the apparent success rate. The paramedics' performance in intubation, as measured by incidence of esophageal intubation, matches that of other systems that use neuromuscular blocking agents.5 Although the use of paralytic agents might improve the fraction of patients successfully intubated, we are aware of no data suggesting that use of paralytic agents for out-of-hospital intubation improves patient outcome. In a correction to be published, gastric distention was noted in 114 (31%) of patients in the BVM group and 98 (27%) of patients in the ETI group (P=.20).

In contrast to the claims of Dr Nieman and colleagues, our study was designed to demonstrate a difference in survival, if one existed. The goal of the intention-to-treat analysis is to yield an unbiased estimate of the effect of ETI in actual practice. It does not address the outcome of a hypothetical population all receiving ETI, nor does such a population exist in EMS practice. Our checks designed to detect "missed" cases found no evidence of selective enrollment.

Nieman et al note our observed increased survival in 2 of 10 subgroups and improved neurological outcome in 3 of 10 subgroups with ETI. If there were truly no effect of ETI, one would expect on average 5 of 10 subgroups to demonstrate improved outcome with ETI and 5 of 10 subgroups to demonstrate worse outcome. Thus, ETI faired worse than chance. Nieman et al state that our study does not address "when should children be intubated." Indeed it does address this question, but with a negative result. Despite almost 3 years of study in one of the largest EMS systems in the world, and the examination of a predetermined set of clinically important patient subgroups, we were unable to identify any subgroup that benefited significantly from ETI. Thus, our study suggests that no subgroup of children should undergo ETI in an urban EMS system with rapid transport times.

When a clinical trial demonstrates equivalence of 2 treatments previously thought to have different efficacies, one must consider both the possibility that the experimental treatment is less effective than hoped, as well as the possibility that the standard therapy is more effective than previously thought. The effectiveness of BVM, coupled with attendant lack of fatal complications, accounts for the decision to remove out-of-hospital pediatric ETI from the paramedic scope of practice in Los Angeles and Orange counties, California.

California Code of Regulations, Title 22, Article 6, §100167, Continuing Education.
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