Is out-of-hospital intubation by paramedics valid enough to be continued?
Is out-of-hospital intubation by paramedics valid enough to be continued?
复制标题
护理人员进行的院外插管是否有效，可以继续进行？
DOI：
10.1007/s00540-011-1138-z
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发表时间：
2011
影响因子：
2.8
通讯作者：
S. Kimura
中科院分区：
文献类型：
--
作者：
M. Morita;Toshimichi Takahashi;Toshiki Kondo;Takahiro Ando;S. Kimura
致编者：Takei等人报道，与气囊-瓣膜-面罩通气和其他气道技术相比，护理人员院外插管与持续自发循环恢复的发生率增加有关。他们的发现与之前的研究一致，这些研究引发了目前世界范围内不愿支持护理人员在院外插管的趋势。在西方国家，护理人员院外插管已经实施了几十年，以改善心脏骤停和重大创伤的结果。越来越多的证据表明，气管插管不是院外护理人员气道管理的最佳方法，可能不利于患者的预后。对于儿科患者和严重多发性创伤和头部损伤的病例，越来越多的文献表明护理人员在院外气管插管的不良生存结果。最近的研究表明，与气囊-瓣膜-面罩通气相比，院外插管与院外心脏骤停患者的出院存活率降低有关[2-4]。根据这些报告的调查结果，一些文章和准则建议停止目前由护理人员进行院外插管的做法。例如，英国一个科学委员会的一项批判性评论得出结论，护理人员在院外插管可能弊大于利。其他指南还建议医护人员在实施复苏时不应进行气管插管。与之前的研究类似，作者发现院外插管并没有改善临床预后（即出院前的生存和神经功能）。他们的数据表明，由护理人员插管可能只会增加医院的负担。他们可能认为，持续的自然循环恢复是评估心脏骤停结果的重要指标。然而，在目前大多数研究院外插管影响的文献中，主要结局指标是存活至出院。他们建议，在有限的适应症标准下，至少在非心源性心脏骤停时，不要停止院外插管。很难确定为什么他们证明继续由护理人员在院外插管是合理的，证据很薄弱，甚至是负面的。作者排除了尝试先进气道管理失败的病例，因为他们预计这些病例的预后较差。在641例病例中，经气管插管认证的医护人员尝试了先进的气道管理。其中，72例高级气道管理失败或停止。也就是说，在超过10%需要高级气道管理的患者中，经插管认证的护理人员未能成功处理气道。作者没有详细描述这些失败的案例，他们在分析中完全抛弃了这些案例。然而，插管尝试后失败的情况是有必要进行深入调查，因为它们可能代表了护理人员插管和气道管理的整体技能。没有尝试就不能插管，任何尝试都可以
To the Editor: Takei et al.[1] reported that out-of-hospital intubation by paramedics was associated with increased incidence of sustained return of spontaneous circulation comparing with bag-valve-mask ventilation and alternative airway techniques. Their findings are consistent with previous studies, which have provoked the current worldwide trend of reluctance to support out-of-hospital intubation by paramedics. Out-of-hospital intubation by paramedics has been implemented for several decades in an effort to improve outcomes from cardiac arrest and major trauma in Western countries. Increasing evidence suggests that tracheal intubation is not the optimal method of out-of-hospital airway management by paramedics and may be detrimental to patient outcome. For pediatric patients and cases of severe multiple trauma and head injury, a developing body of literature indicates adverse survival outcome of out-ofhospital tracheal intubation by paramedics. The most recent studies have shown that out-of-hospital intubation is associated with decreased survival to hospital discharge among out-of-hospital cardiac arrest patients comparing with bag-valve-mask ventilation [2–4]. In the light of the findings of these reports, a number of articles and guidelines recommend discontinuing the current practices of outof-hospital intubation by paramedics. For instance, a critical review from a scientific UK committee concluded that out-of-hospital intubation by paramedics was more likely to be harmful than beneficial [5]. Other guidelines also recommend that paramedics should not perform tracheal intubation when performing resuscitation [6]. Similar to previous studies, the authors revealed that out-of-hospital intubation did not improve clinically robust outcomes (ie, survival to discharge and neurological performance). Their data implied that intubation by paramedics might only result in increased burden for hospitals. They might consider that sustained return of spontaneous circulation was a significant measure to evaluate the outcome of cardiac arrests. However, the primary outcome measure has been survival to hospital discharge in most of the current literature investigating the impact of out-ofhospital intubation. They suggested not to discontinue outof-hospital intubation under limited indication criteria, at least in cardiac arrest with noncardiac origin. It is hard to determine the reason why they justified continuing out-ofhospital intubation by paramedics with tenuous or even negative evidence to support it. The authors excluded the cases where attempts of advanced airway management failed because they expected poor prognosis of such cases [1]. In 641 cases, advanced airway management was attempted by intubation-certified paramedics. Of those, advanced airway management failed or was discontinued in 72 cases. That is, intubation-certified paramedics did not successfully handle the airway in more than 10% of the patients requiring advanced airway management. The authors did not depict these failed cases in detail, and they completely abandoned them in their analysis. However, the failed cases after intubation attempts are necessary to be investigated intensely because they might represent the overall skills of intubation and airway management by paramedics. No intubation will be accomplished without an attempt, and any attempts could