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Rapid sequence intubation: how do we define success?

Ottawa, Ontario

To the Editor:

Dr. Kovacs et al.¹ should be commended for publishing their rapid sequence intubation (RSI) review in an anesthesia journal. For far too long, airway management literature has proceeded in parallel between emergency medicine, anesthesiology and others rather than in collaboration. Hopefully, future initiatives could improve this unfortunate division.

I question the evidence that "airway management should be performed by the person with the greatest experience for that (particular) setting". Should it not be the most qualified person available? An anesthesiologist who has performed thousands of intubations, albeit mostly in the operating room, will undoubtedly be better than the person who has performed considerably fewer intubations. The number of rescue intubations performed by anesthesiologists in my hospital after failed attempts in the emergency room, including RSI, is not negligible. A 97% success rate for RSI may sound high but I counter that a 3% failure rate with muscle relaxants may not be acceptable. The paper correctly suggests that surrogate outcomes, including intubation success rate, are all that is commonly reported. Mortality and morbidity benefits should however be the focus of future studies. Evidence of adverse consequences of RSI by paramedics^2,3 challenges the notion that widespread dissemination of RSI is necessary. Far too often there is a rush to protect the airway by immediate intubation even though it is patent and there is no hypoxemia. A delay in intubation may increase the aspiration risk but this will often be offset by the benefit gained from having a more proficient intubation performed later. The focus is to secure the airway in the best and safest fashion by the most qualified available person. Education initiatives, including the AIME® program, may increase the number of truly qualified people. In regards to AIME®, what is the background of the instructors? (i.e., emergentologists, anesthesiologist, surgeons, etc.).

References

1 Kovacs G, Law JA, Ross J, et al. Acute airway management in the emergency department by non-anesthesiologists. Can J Anesth 2004; 51: 174–80.[Abstract/Free Full Text]

2 Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients with severe head injury. J Trauma 2000; 49: 1065–70.[Medline]

3 Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma 2003; 54: 444–53.[Medline]

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