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Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Contributing EditorIndividualAuthor
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
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.
Gausche M, Lewis RJ. Out-of-Hospital Endotracheal Intubation of Children—Reply. JAMA. 2000;283(21):2790–2792. doi:10.1001/jama.283.21.2787
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