Multivariate predictors of failed prehospital endotracheal intubation
Multivariate predictors of failed prehospital endotracheal intubation
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DOI：
10.1197/aemj.10.7.717
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发表时间：
2003-07-01
影响因子：
4.4
通讯作者：
Yealy, DM
中科院分区：
文献类型：
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作者：
Wang, HE;Kupas, DF;Yealy, DM
目的：常规训练的院外救援人员（如护理人员）通常无法在需要侵入性气道管理的患者中完成气管插管（ETI）。先前的研究已经确定了与院外ETI失败相关的单变量变量，但尚未研究影响ETI成功的众多因素之间的相互作用。本研究试图使用多元逻辑回归来确定一组与成人院外ETI失败相关的因素。研究方法：作者从院前气道协作评价中获得了临床和人口统计学数据，这是一项涉及宾夕法尼亚州高级生命支持（ALS）紧急医疗服务（EMS）系统的前瞻性多中心观察性研究。提供者使用标准表格报告尝试ETI的详细信息，包括系统和患者人口统计学资料、使用的方法、遇到的困难和初步结果。作者排除了镇静辅助和神经肌肉阻滞辅助插管的数据。主要结局指标是ETI失败，定义为在最后一次院外喉镜检查尝试中未能成功放置气管内导管。进行逻辑回归，以建立一个多变量模型，识别与ETI失败相关的因素。结果：数据来自45个ALS系统，在2001年6月1日至2001年11月30日期间尝试的663例成人ETIs。ETT失败89例（失败率13.4%）。在61个可能与ETI失败相关的因素中，多变量logistic回归显示以下与ETI失败相关的显著协变量（比值比; 95%置信区间;似然比p值）：存在牙关紧闭/牙关紧闭（9.718; 95% CI = 4.594至20.558; p <0.0001）;无法将气管内导管通过声带（7.653; 95% CI = 3.561至16.447; p <0.0001）;无法看到声带（7.638; 95% CI = 3.966至14.707; p <0.0001）;完整的咽反射（7.060; 95% CI = 3.552至14.033; p <0.0001）;在尝试ETI之前建立静脉通路（3.180; 95% CI = 1.640至6.164; p = 0.0005）;体重增加（顺序量表）（1.555; 95% CI = 1.242 - 1.947; p = 0.0001）;在尝试ETI前建立心电图监测（0.199; 95% CI = 0.084至0.469; p = 0.0003）。该模型是评价的模型中最简约的，并表现出良好的拟合（Hosmer-Lemeshow检验p = 0.471）和区分度（ROC曲线下面积0.906）。没有显著的相互作用项。结论：作者使用多变量逻辑回归来确定一组与成人院外患者未能完成ETI相关的因素。该分析的结果可以为临床方案或决策规则提供基础，旨在最大限度地减少院外ETI失败的发生率。
Objectives: Conventionally trained out-of-hospital rescuers (such as paramedics) often fail to accomplish endotracheal intubation (ETI) in patients requiring invasive airway management. Previous studies have identified univariate variables associated with failed out-of-hospital ETI but have not examined the interaction between the numerous factors impacting ETI success. This study sought to use multivariate logistic regression to identify a set of factors associated with failed adult out-of-hospital ETI. Methods: The authors obtained clinical and demographic data from the Prehospital Airway Collaborative Evaluation, a prospective, multicentered observational study involving advanced life support (ALS) emergency medical services (EMS) systems in the Commonwealth of Pennsylvania. Providers used standard forms to report details of attempted ETI, including system and patient demographics, methods used, difficulties encountered, and initial outcomes. The authors excluded data from sedation-facilitated and neuromuscular blockade-assisted intubations. The main outcome measure was ETI failure, defined as failure to successfully place an endotracheal tube on the last out-of-hospital laryngoscopy attempt. Logistic regression was performed to develop a multivariate model identifying factors associated with failed ETI. Results: Data were used from 45 ALS systems on 663 adult ETIs attempted during the period June 1, 2001, to November 30, 2001. There were 89 cases of failed ETT (failure rate 13.4%). Of 61 factors potentially related to ETI failure, multivariate logistic regression revealed the following significant covariates associated with ETI failure (odds ratio; 95% confidence interval; likelihood ratio p-value): presence of clenched jaw/trismus (9.718; 95% CI = 4.594 to 20.558; p < 0.0001); inability to pass the endotracheal tube through the vocal cords (7.653; 95% CI = 3.561 to 16.447; p < 0.0001); inability to visualize the vocal cords (7.638; 95% CI = 3.966 to 14.707; p < 0.0001); intact gag reflex (7.060; 95% CI = 3.552 to 14.033; p < 0.0001); intravenous access established prior to ETI attempt (3.180; 95% CI = 1.640 to 6.164; p = 0.0005); increased weight (ordinal scale) (1.555; 95% CI = 1.242 to 1.947; p = 0.0001); and electrocardiographic monitoring established prior to ETI attempt (0.199; 95% CI = 0.084 to 0.469; p = 0.0003). This model was the most parsimonious of the models evaluated and demonstrated good fit (Hosmer-Lemeshow test p = 0.471) and discrimination (area under ROC curve 0.906). There were no significant interaction terms. Conclusions: The authors used multivariate logistic regression to identify a set of factors associated with failure to accomplish ETI in adult out-of-hospital patients. Findings from this analysis could provide the basis for clinical protocols or decision rules aimed at minimizing the incidence of out-of-hospital ETI failure.