Prehospital intubation in cardiac arrest: the debate continues.

Advancedpre-hospital airwaymanagement is a rapidly evolving nd controversial area. The paper by Wang et al. published in this ssue of the journal further adds to that debate.1 Wang and colleagues are to be congratulated on reporting such large dataset, and adding significantly to the body of knowledge. hey have documented the prehospital use of tracheal intubation nd alternative airway devices in 16 American states in 2008. A full ange of clinical conditions were included but the majority were in ardiac arrest, providing important information about this group of atients. Tracheal intubation has been used in pre-hospital cardiac arrest ince the 1970s, and has become known as the “gold standard” f care. However, it must be remembered that when this practice egan there were no readily available supraglottic airway devices, nd the only real alternative to tracheal intubation was bag-mask entilation. Recently, several publicationshave suggested that tracheal intuation may not be the best technique for pre-hospital airway anagement in cardiac arrest.2 The reasons to suggest this are ulti-factorial, and well highlighted by this paper. Tracheal intubation is a highly technical skill, with a learning urve of up to 60 procedures.3 In addition, skill fade will occur hen there is a lack of regular exposure to the procedure: EMS roviders in the UK perform tracheal intubation between 1 and 4 imes annually.4 This rate of exposure is supported by the findngs of Wang and colleagues, with intubation attempted once n every 225 patient care episodes. An EMS provider attending 000 patients annually will therefore attempt intubation only four imes. Some EMS systemsmake provision to increase exposure by limting the skill to smaller teams who are selectively tasked to such vents; the German Notarzt system and recently introduced “critcal care paramedics” in the UK are examples of this. However the nevitable consequence is that general EMS providers will lose the kill, and it is hard to identify a way of increasing exposure of all roviders except through simulation or placement in other setings (e.g. hospital operating theatres)which is expensive andoften ogistically challenging. Tracheal intubation can provide very effective ventilation if erformed correctly, but is associated with a number of major omplications. The most important is unrecognised oesophageal ntubation, rendering the patient effectively apnoeic until the sitution is identified and rectified. An oesophageal intubation rate of .5% was reported in this study, with immediate recognition in the ajority of cases. However the self-reporting methodology makes his a likely underestimate, and other papers suggest higher rates f unrecognised non-tracheal intubation.5 This remains an impor-