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Intubation – A high or low priority?

December 11, 2009 By 2 Comments

IntubationCurrent2_tcm16-210658A common theme around hospitals and the latest ACLS guidelines suggest that intubation should no longer be considered a high priority. Instead it is now recommended that high-quality CPR and early defibrillation take priority over all other ALS interventions. I for one feel differently when it comes to pre-hospital care.

According to the American Heart Association, other procedures like IV access and medication adminstration can be performed before intubation if adequate ventillations are taking place by means of a bag-valve-mask. While I certainly agree with the concept, I do not feel that it is very practical for situations when EMS is involved. Unlike hospital settings, EMS workers have to deal with bumpy roads, tight corners, environmental factors and limited room in most ambulances. It can be extremely difficult to maintain a good seal and adequately ventilate a patient in those conditions.

Early intubation frees up hands, limits the amount of time suction is needed and allows paramedics to focus on interventions like chest compressions, defibrillation and medication adminstration.

I am not saying that I completely dissagree with the new ACLS guidelines. I simply feel that pre-hospital care was not taken into consideration when they were released. I would be interested to see how much of the Heart Association’s research was done on pre-hospital cases.

As always, feel free to e-mail me with any questions or comments.


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  • DFord38

    I disagree with you completely. A patient in cardiac arrest needs 3 things: CPR, Defib,  and Medications.  By providing early and continuous CPR, we ensure that CPP is met, thus greatly enhancing the chance of survival.  Countless studies have been done on this. You may be interested in reading “Apneic oxygenation of man”… very interesting case study.

    • Michael

      The article is about the priority for intubation. 

      This is the case study which looks at respiratory acidosis in planned minor operations and also at the previous studies on dogs, which look at whether there is any recordable acidotic damage or ECG changes due to the lack of ventilations in the subjects. 

      I am not really sure how this directly relates to whether paramedics should be intubating or not.

      It is useful to have a discussion about ventilations and the effectiveness of O2 supply and whether the body requires this not. That is a discussion for physiologists and cardiologists to have, and if it is proved that ventilation support can be altered, it will filter down to EMS at some point.

      At last look, American Heart Association, The UK Resuscitation Council, European Resuscitation Council and the Resuscitation Council of Australia & New Zealand all advocate high flow for post MI patients, or supported ventilations with high O2 concentrations due to ischaemia and or organ infarction. Until that changes, discussions about apnoeic respiratory acidosis are outside the main discussion topic. 

      The age-old concern mentioned, to my humble understanding is, whether EMS should go for an advanced airway, in cardiac arrest or other situations?

      Without a doubt, LMA’s can provide suitable airway protection in many patients as can the combi-tube. Simple airway manoeuvres have also been proven to be effective sometimes. 

      The issues we have is that studies on airway management have been conducted in hospital, by patients who have been fasted (little chance of aspiration), and by those with minor ops or whom have already been identified as potential high risk patients and are observed on a high dependency unit. It was actually patients on a HDU during the study of nurse initiated resuscitation without advanced airways that kicked off this debate some years ago.

      The failings with this and other studies is that they do not address the entire population group that have adult cardiac arrest in the community nor do they address the systems and responders in EMS. 

      To draw conclusions on selected studies that are not comparable is just as bad as choosing to do something, because “we’ve always done it”. What is needed is a evidenced based study on out-of-hospital airway management for all patient types in all possible situations. Then the best practice of current understanding created from that.

      If evidence suggest intubation is bad for the patient, then it should be given up in favour of something better for patient outcome.
      If however, intubation is better for some situations, then that should remain the Gold Standard and the issues about training and skill retention can be addressed along with the debates about neuromuscular blockade. 
      It is the skill practice and the issues around pharmacology that I suggest lie at the heart of this debate and not about the use or need of intubation as a skill.

      There are too many egos and professional titles blurring the real issues. It comes from all angles and masks itself with different debates.

      Fundamentally, we need to know what is best for the patient and how do we equip EMS to provide that recognised best, in the situational setting of out-of-hospital care?

      That should be our aim.