Intervention Review

Emergency intubation for acutely ill and injured patients

  1. Fiona Lecky1,*,
  2. Daniele Bryden2,
  3. Rod Little3,
  4. Nam Tong4,
  5. Chris Moulton5

Editorial Group: Cochrane Injuries Group

Published Online: 23 APR 2008

Assessed as up-to-date: 3 DEC 2007

DOI: 10.1002/14651858.CD001429.pub2


How to Cite

Lecky F, Bryden D, Little R, Tong N, Moulton C. Emergency intubation for acutely ill and injured patients. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001429. DOI: 10.1002/14651858.CD001429.pub2.

Author Information

  1. 1

    Hope Hospital, Department of Emergency Medicine, Salford, UK

  2. 2

    Royal Hallamshire Hospital, Intensive Care Unit, Sheffield, UK

  3. 3

    University of Manchester, Medicine, Isle of Mull, UK

  4. 4

    Queen Elizabeth Hospital, Emergency Medicine, Kings Lynn, Norfolk, UK

  5. 5

    Royal Bolton Hospital, Accident & Emergency, Bolton, UK

*Fiona Lecky, Department of Emergency Medicine, Hope Hospital, Clinical Sciences Building, Eccles Old Road, Salford, M6 8HD, UK. fiona.lecky@manchester.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 23 APR 2008

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Emergency intubation has been widely advocated as a life saving procedure in severe acute illness and injury associated with real or potential compromises to the patient's airway and ventilation. However, some initial data have suggested a lack of observed benefit.

Objectives

To determine in acutely ill and injured patients who have real or anticipated problems in maintaining an adequate airway whether emergency endotracheal intubation, as opposed to other airway management techniques, improves the outcome in terms of survival, degree of disability at discharge or length of stay and complications occurring in hospital.

Search methods

We searched the Cochrane Injuries Group Specialised Register (December 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (1950 to November 2006), EMBASE (1980 to week 50, December 2006), National Research Register (Issue 4, 2006), CINAHL (1980 to December 2006), BIDS (to December 2006) and ICNARC (to December 2006). We also examined reference lists of articles for relevant material and contacted experts in the field. Non-English language publications were searched for and examined.

Selection criteria

All randomised (RCTs) or controlled clinical trials involving the emergency use of endotracheal intubation in the injured or acutely ill patient were examined.

Data collection and analysis

The full texts of 452 studies were reviewed independently by two authors using a standard form. Where the review authors felt a study may be relevant for inclusion in the final review or disagreed, the authors examined the study and a collective decision was made regarding its inclusion or exclusion from the review. The results were not combined in a meta-analysis due to the heterogeneity of patients, practitioners and alternatives to intubation that were used.

Main results

We identified three eligible RCTs carried out in urban environments. Two trials involved adults with non-traumatic out-of-hospital cardiac arrest. One of these trials found a non-significant survival disadvantage in patients randomised to receive a physician-operated intubation versus a combi-tube (RR 0.44, 95% CI 0.09 to 1.99). The second trial detected a non-significant survival disadvantage in patients randomised to paramedic intubation versus an oesophageal gastric airway (RR 0.86, 95% CI 0.39 to 1.90). The third included study was a trial of children requiring airway intervention in the prehospital environment. The results indicated no difference in survival (OR 0.82, 95% CI 0.61 to 1.11) or neurologic outcome (OR 0.87, 95% CI 0.62 to 1.22) between paramedic intubation versus bag-valve-mask ventilation and later hospital intubation by emergency physicians; however, only 42% of the children randomised to paramedic endotracheal intubation actually received it.

Authors' conclusions

The efficacy of emergency intubation as currently practised has not been rigorously studied. The skill level of the operator may be key in determining efficacy.
In non-traumatic cardiac arrest, it is unlikely that intubation carries the same life saving benefit as early defibrillation and bystander cardiopulmonary resuscitation (CPR).
In trauma and paediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems.
It would be ethical and pertinent to initiate a large, high quality randomised trial comparing the efficacy of competently practised emergency intubation with basic bag-valve-mask manoeuvres (BVM) in urban adult out-of-hospital non-traumatic cardiac arrest.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Emergency endotracheal intubation (placing a tube through the mouth and throat into the lungs) may reduce deaths from acute illness and injury, but more research is necessary.

Acute illness and injury are the most common causes of death and disability worldwide in people aged under 50 years. The highest priority in an emergency is to enable a patient to breathe by securing their airway (passage from the nose and mouth into the lungs). Endotracheal intubation is one of various ways to secure the airway. This review found no difference between endotracheal intubation and other airway securing strategies for reducing deaths after acute illness or injury; however, better studies are needed.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

急性疾病及創傷患者之緊急插管

對於急性疾病及有確實或潛在呼吸道及換氣傷害的患者,緊急插管已廣泛的被建議用於維持生命,然而,有些起始的數據暗示缺乏可見的效益。

目標

為了確定在有確實或預期有呼吸道維持問題的急性疾病及受傷患者上,緊急氣管插管相對於其他呼吸道維持技術,是否可改善存活期、出院時殘障的程度、住院天數及住院時的併發症等結果。

搜尋策略

我們搜尋Cochrane Injuries Group Specialised Register (December 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (1950 to November 2006), EMBASE (1980 to week 50, December 2006), National Research Register (Issue 4, 2006), CINAHL (1980 to December 2006), BIDS (to December 2006) and ICNARC (to December 2006)。 我們還檢查文章的參考文獻看有沒有相關的資料並與在此領域的專家接洽。非英語出版也加搜尋檢查。

選擇標準

所有有關受傷或急性疾病患者需緊急使用氣管內管的隨機控制或控制臨床試驗皆加以檢查。

資料收集與分析

兩名作者(使用一個標準格式)各自評論了452個研究的全文。如果評論作者在最後審查時,有認為可能適合納入或不符合納入之研究,作者審查研究並共同決定研究要納入評論或排除於評論外。因為病人,醫生和替代插管技術的異質性,評論的結果並無進行統合分析。

主要結論

我們鑑定出3個在都市環境裡進行的合格臨床隨機控制試驗。兩個試驗是關於在醫院外心跳停止之非創傷性成人。這些試驗發現病患隨機接受醫生插管與combitube的處置並無存在顯著性的存活不利 (RR 0.44, 95% CI 0.09 to 1.99). 第2個試驗發現病患隨機接受醫務輔助人員插管與oesophageal gastric airway的處置並無存在顯著性的存活不利(RR 0.86, 95% CI 0.39 to 1.90). 第3 個trial包括孩子到院前的環境需要氣道處置的研究。在比較醫務輔助人員插管, bagvalvemask 通氣和晚些時候在醫院急診醫師插管,結果顯示沒有存活的差別(OR 0.82,95% CI 0.61 to 1.11)或者神經病學的結果(OR 0.87,95% CI 0.62 to 1.22),不過,隨機接受醫務輔助人員插管的孩子只有42%實際上完成插管。

作者結論

目前來說,緊急插管的功效並未被嚴謹的研究。操作者的技能水準是影響效力的關鍵.在非創傷性的心動停止,插管不太可能與盡快去顫和旁觀者心肺復甦術有相同的救生效益。在都市環境,創傷和兒科病患方面,目前證據基礎是不提供緊急的到醫院前插管。在都市環境,對於醫院外成年非創傷性心跳停止的情況,啟動一個大規模,高品質臨床隨機控制試驗,來比較緊急插管與使用bagvalvemask(BVM)處置的效力差異是恰當且具倫理性的。

翻譯人

本摘要由高雄榮民總醫院葉宣德翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於急性並且受傷害的病患,緊急插管(透過嘴巴和咽喉放置氣管內管進肺)可能降低急性病和損傷,但須更多的研究。急性病和損傷是導致50歲以下死亡和生理殘障最普遍的原因。在危急的時候,優先使病患能夠保護他們氣道並維持呼吸(從鼻子和嘴通氣進肺),氣管內插管是保護氣道的各種方法之一。這篇回顧性文章發現,氣管內插管和保護氣道的各種方法在降低死亡率的比較上並無差別;不過,需要更好的研究。