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The question of "How many angels can dance on the head of a pin?" is
sometimes used as a rhetorical illustration of the futility of meaningless
or esoteric debate, and in the paper by Clements and colleagues which
discusses whether children in the prehospital environment should be
treated with a cuffed or uncuffed tracheal tube, the authors come quite
close to trying to count those angels.
Contrary to the image conjured up of teams of paediatric airway
specialists poised to descend on sick children in the community, the
reality is somewhat different. The vast majority of children will be
treated by paramedics and ambulance technicians - sometimes assisted by
volunteer immediate care physicians or GPs - very few of whom are likely
to possess that rare combination of skill, equipment and drugs necessary
to intubate children outside hospital in reasonable safety.
Most seasoned emergency physicians will have seen cases of
unrecognised tracheal tube misplacement in prehospital care, and it is
partly in recognition of the disaster that accompanies such events, that
the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) has recently
signalled that it wants to readdress the value of the tracheal tube in
paramedic practice. Yet there are still those diehards within the UK's
ambulance services who cling to the notion that the tracheal tube is the
gold standard of prehospital airway management, despite compelling
evidence to the contrary.[3,4] The increasing availability of affordable,
portable, electronic capnometers goes only part of the way to addressing
the overall problem, since these will not prevent those unnecessary
periods of intensified hypoxaemia that accompany repeated failed attempts
at intubation. We need to keep reminding ourselves that patients die from
a failure to oxygenate and a failure to ventilate, not from a failure to
intubate, and there is now a growing view that supraglottic airway devices
(SADs) are better and safer options in the hands of non-anaesthetists who
work in the prehospital environment. It could even be that SADs are
superior to the tracheal tube in the hands those few skilled anaesthetists
who do venture out into the community, but I can find no evidence that a
comparative trial has ever been undertaken to test this hypothesis.
Clements and colleagues are right to say that we should always be
ready to challenge doctrine, but I would suggest that the doctrine that
most needs to be challenged is the one that confers gold standard status
on the tracheal tube in prehospital care. If the trend away from
intubation continues, the question as to whether a child’s tracheal tube
should be cuffed or uncuffed could soon become an irrelevance for the vast
majority of prehospital providers.
1 Clements RS, Steel AG, Bates AT, Mackenzie R. Cuffed endotracheal
tube use in paediatric prehospital intubation: challenging the doctrine?
Emerg Med J 2007;24:57-58.
2 Clark T, Sagar A, Whitmore D. Developing paramedic practice 2006 at
the RCA. Ambulance UK Oct 2006;21(5):300.
3 Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the
prehospital airway: a comparison of laryngeal mask insertion and
endotracheal intubation by UK paramedics. Emerg Med J 2005;22:66-67.
4 Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an
urban emergency medical services system. Ann Emerg Med 2001;37:62-4.
Competing interests: AMM is clinical adviser to The Laryngeal Mask
Company Ltd, St Helier, Jersey, Channel Islands, UK; and also to Intavent
Orthofix Ltd, Maidenhead, UK, distributor of LMA devices in the UK and
Eire. Both are unsalaried positions, but the author has received payment
for advisory work undertaken for both companies in connection with the use
of LMA devices in prehospital care.