Skip to main content

Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis

Abstract

Background

Clinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team.

Methods

We searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions.

Results

Forty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants.

Conclusion

Physician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.

Background

Airway management is a critical component of prehospital care for severely ill and injured children. Airway management is arguably even more important in children than in adults, as cardiac arrest is more likely to be hypoxic in origin and therefore amenable to airway and ventilation intervention. As hypoxia correction is a time critical intervention, an emergency medical service (EMS) system must be able to provide airway management as early as possible, preferably at the incident scene.

Intubation is generally considered to be the gold standard for airway management in the critically ill and injured. Children however typically comprise only about 5% of total EMS cases [1,2,3], and those requiring intubation vary from 0.1% of all EMS responses [3, 4] to approximately 5% of paediatric cases when advanced intervention teams are selectively utilised [1, 2]. Success rates are also reported to be lower in children and the complication rate higher [5, 6]. Traditionally, ground EMS systems have intubated children without muscle relaxants, but many systems are introducing relaxants into their clinical protocols with the expectation that overall success rates would improve and that intubation could be offered for a wider range of pathologies. There are also recent reports that physician staffed helicopter EMS (PS-HEMS) may produce particularly high procedural success with low complication rates [7,8,9,10].

The purpose of this study was to systematically review the available literature and perform a meta-analysis to determine whether there exists an association between type of prehospital team and intubation success and complication rates.

We hypothesised that utilisation of muscle relaxants by non-physician teams would improve procedural success in prehospital paediatric intubation over teams without relaxant access and that the greater experience and training of physician teams might produce further performance gains above those associated with relaxant access for non-physician teams.

Methods

The systematic review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Guidelines [11].

Data sources and literature search strategy

We created search strategies for the concepts of ‘intubation’, ‘prehospital’, and ‘paediatric’ using a combination of standardised terms and keywords drawn from indices, thesauri, and on-topic articles (Supplementary eAppendix) in consultation with a medical librarian. The electronic databases Ovid MEDLINE, EMBASE, and CINAHL were searched from database inception to November 11, 2019. Additionally, we conducted a manual search of reference lists of included and other relevant articles. All articles were reviewed for inclusion by two independent reviewers (AG and NB). Any discrepancies were resolved by consensus with a third reviewer (AW).

Study selection

Interventional and/or observational studies were eligible for inclusion if they reported data on the success, first-pass success, and/or complication rates of prehospital paediatric intubation attempts. Studies that did not separately report the number of patients in whom intubation was attempted were excluded from analysis, as were abstract-only and grey literature reports. There was no language restriction.

Data extraction

Successful intubation, first-pass success rate, and complication rates were extracted from the included articles by two independent investigators (AG and NB). Where there was discrepancy, a third author (AL) adjudicated. We also extracted data about authors, publication year, study location, setting, professional background of team members, availability of muscle relaxants, and participant characteristics by inclusion age and intubation indication. For each study, the team composition (exposure variable) was classified into three groups: non-physicians with no relaxants, non-physicians with relaxants, and physicians with relaxants. We made no contact with authors for missing data as many studies were old.

Outcomes

The primary outcomes were the proportions of overall intubation and first look success rates. Secondary outcomes included the rate of intubation complications, specifically unrecognised oesophageal and endobronchial intubation, three or more attempts at intubation, hypoxia, or aspiration.

Assessment of study quality

The criteria used by Fouche and colleagues [12] were used to evaluate study quality. The checklist consists of 8 items that assess external and internal validity through 4 domains: selection bias, non-response bias, measurement bias, and bias related to the analysis, with each item graded as low or high [12]. The overall risk of bias for the study was rated ‘low’ if 7 or more domains were rated low, ‘moderate’ if 4 to 6 domains were rated low, and ‘high’ if 1 to 3 domains were rated low [12]. Each included study was assessed by AL and reviewed by AG.

Data synthesis and statistical analysis

We used the macro ‘metaprop_one’ in STATA 16.0 (StataCorp, College Station, TX) to pool proportions using the Freeman-Tukey double arcsine option to ensure that the confidence intervals around the estimates did not fall outside 0 or 1 with stable variances [13]. We used a logistic-normal random-effects model [13] and assessed the heterogeneity as low, moderate, and high using I2 values of 25%, 50%, and 75% [14]. We performed subgroup analyses by team composition a priori to explain heterogeneity and conducted a sensitivity analysis on low risk of bias trials to estimate the robustness of primary outcome results. Meta-regression with robust variance estimates (to take into account within-study correlation between different team types) was used to explore differences in the primary outcomes by team composition subgroups over time (year of publication) [15]. As there were large variations in the clinical population (mixed, trauma, head injury, and arrested) studied, subgroup meta-analyses by team composition were also performed for the overall intubation rate, first-pass success rate, and overall airway complication rate. We did not assess publication bias with a funnel plot as it has been shown to be problematic in meta-analysis of proportions [16].

Results

Search results

The search strategy yielded 40 eligible studies included in the analysis (Fig. 1). The characteristics of 40 included studies involving 11,567 children are shown in Table 1 [1, 3, 5,6,7,8,9,10, 17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]. Fifteen studies (8201 participants) were published from 2015 onwards. The median (IQR) sample size of the studies was 86 (36 to 270). Twenty-six studies were published in the USA, five in Australia, two in the Netherlands, and one each in Belgium, Denmark, Finland, France, Germany, Switzerland, and the UK from 1989 to 2019.

Fig. 1
figure1

Systematic review flow chart

Table 1 Characteristics of the included studies. Oesophageal intubation refers specifically to unrecognised oesophageal intubation. All physician teams utilised muscle relaxants

Five studies [7, 8, 28, 32, 38] compared outcomes between different intubator groups, and one study [37] described outcomes before and after implementation of national guidelines. Of the 46 described team compositions, 22 studies utilised non-physicians with no relaxants (n = 7602), 12 utilised non-physicians with relaxants (n = 2185), and 12 utilised physicians, all with relaxants (n = 1780). Studies published before 2010 were mainly non-physicians with no relaxants (15/20). Since 2010, 11 of 12 studies involved physicians. Mode of transportation was road (24/46), helicopter (10/46), and both road and helicopter (12/46).

Quality assessment

None of the 40 studies were rated as high risk of bias. Eighteen studies (n = 7820) were rated moderate risk of bias, and 22 studies (n = 3747) had overall low risk of bias. Main reasons for biases for individual studies are shown in Fig. 2. Selection bias (items 1 to 3) was present in 16 studies (Fig. 3). Non-response bias (item 4) more than 20% was the most common type of bias affecting external validity (Fig. 3).

Fig. 2
figure2

Review authors’ judgements about each risk of bias item for each included study. Low and high risk of bias are represented as green and red symbols, respectively

Fig. 3
figure3

Review authors’ judgements about each risk of bias item presented as percentages across all included studies

Overall intubation and first-pass success rates

Thirty-five studies (40 reports by a specific team type) in 10,456 children examined the overall success intubation rates, with most data coming from non-physician teams without relaxants (n = 7181). There was a significant intra-group heterogeneity (I2 > 72% for all three team composition groups) and a significant inter-group heterogeneity (P < 0.001), supporting the separate reporting of overall success intubation rates by subgroups. Non-physician teams without relaxants had lower overall success rates (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%) (Fig. 4). Differences in overall success rates by team composition were significant (P < 0.001) after adjusting for time (− 0.3%/year, 95% CI − 0.8%/year to 0.3%/year, P = 0.29) (Fig. 5).

Fig. 4
figure4

Pooled proportion for overall intubation success by clinical team groups

Fig. 5
figure5

Meta-regression of overall intubation success over time (year of publication). Meta-regression lines are drawn for each clinical team group

The sensitivity analysis of 21 low risk of bias studies (24 team composition groups) in 3707 children showed similar results, with non-physician teams without relaxants having lower overall success rates (73%, 95% CI 64–81%) than non-physician teams with relaxants (96%, 95% CI 92–99%) and physician teams (99%, 95% CI 97–100%). Meta-regression in low risk of bias studies showed that team composition differences in overall success rates remained significant (P < 0.001) after adjusting for time (− 0.9%/year, 95% CI − 0.1%/year to − 1.6%/year, P = 0.04).

Eighteen studies in 2752 children examined first-pass success rates (Fig. 6). There was a significant intra-group heterogeneity (P < 0.001) and a significant inter-group heterogeneity (P < 0.001), supporting the separate reporting of first-pass success intubation rates by subgroups. Physician teams had significantly higher first-pass success rates (91%, 95% CI 86–95%) than non-physician teams with relaxants (75%, 95% CI 69–81%) or without relaxants (55%, 95% CI 48–63%). Meta-regression was problematic as the degrees of freedom were less than 4 [15]. Sensitivity analysis in 12 low risk of bias studies (n = 1843) showed significant inter-group heterogeneity (P < 0.001), with physician teams associated with higher first-pass success rates (92%, 95% CI 87–96%) than non-physician teams with relaxants (73%, 95% CI 67–78%) or without relaxants (47%, 95% CI 35–59%).

Fig. 6
figure6

Pooled proportion for first-pass success by clinical team groups

Adverse events

Most adverse events by team type showed large intra-group and inter-group heterogeneity, supporting the need to report individual team pooled estimates (Table 2). Sixteen studies, involving 1975 children, examined the overall intubation complication rate. The overall airway complication rate was lower in physician teams than in non-physicians with and without relaxants (Table 2). Physician teams were not associated with the occurrence of oesophageal intubations, aspirations, or the need for three or more multiple intubation attempts (P = 1.00, P = 0.27, P = 0.24, respectively).

Table 2 Summary of findings for adverse events by team composition

As there was no inter-group heterogeneity for endobronchial intubation (P = 0.15), the overall pooled estimated was 7% (95% CI 3–12%) (Table 2). However, Simons and colleagues’ study [44] appears to be an outlier (21%, 95% CI 10–37%) as there were exhaustive attempts to determine the endotracheal tube position after arrival in the emergency department. A post hoc sensitivity analysis, excluding Simons and colleagues’ study [44], showed that there was a significant inter-group heterogeneity (P < 0.001), with a pooled estimate for physician team decreasing to 0% (95% CI 0–2%).

Of the 40 studies included in this systematic review, only six [7, 10, 30, 37, 45, 46] (651 children) reported hypoxia after intubation. Much of the meta-analysis result was influenced by Martinon and colleagues’ study [37] (n = 296) that examined the effect of national guidelines on prehospital intubation in severely head-injured children. A post hoc sensitivity analysis, excluding Martinon and colleagues’ study [37], showed that there was a significant inter-group heterogeneity (P < 0.001), with a pooled estimate for physician team decreasing to 3% (95% CI 0–10%).

Outcomes by clinical population

Seven studies were in trauma patients (n = 500) [21, 26, 34, 39,40,41, 44], six in arrested patients (n = 804) [5, 17, 25, 29, 33, 38], and three in head injury patients (n = 414) [6, 31, 37], and the remaining studies comprised a mixed population of all patients requiring airway management (n = 9849). There was no association between team composition and type of paediatric patients treated (P = 0.875). Non-physicians with or without relaxants had lower rates of overall intubation success in arrested patients compared with other patient populations (Table 3). The first-pass success rate and overall airway complication rate by patient population and team composition are shown in Table 3.

Table 3 Summary of findings for overall successful intubation, first-pass success, and overall airway complication rates by patient population and team composition

Discussion

To our knowledge, this is the first meta-analysis to compare prehospital intubation success and complication rates of different teams of intubator providers specifically in children. The success and complication rates for physician teams are better than non-physician teams either with or without muscle relaxants. Although reported clinical populations varied between studies, the success and complications rates followed the same pattern when population subgroup meta-analyses were performed. The overall success and first-pass success estimates were robust in the sensitivity analyses. Even after adjusting for the year of publication in the meta-regressions, team composition differences in the overall success estimate remained significant. The overall quality of evidence was graded as moderate to high after assessing for the presence of selection and non-response bias, measurement bias, and bias related to data analysis [12].

Two previous meta-analyses [12, 49] examining the success and complication rates by physician and non-physician teams regardless of patient age where both team types utilised relaxants demonstrated higher overall and first-pass success for physician teams compared with non-physician teams. Our review indicates that this is also observed in the paediatric subgroup. A possible contributor to higher success rates by physician teams is in-hospital exposure to paediatric intubation compensating for the rare requirement for this procedure in prehospital practice. All of the identified physician team studies utilised HEMS for at least some responses, and it may be that there is an additive effect from HEMS increasing team experience by allowing small numbers of clinicians to cover a larger population thereby concentrating exposure. As non-physician teams utilising relaxants have higher success rates when transported by HEMS compared with ground transport lends additional support to this theory.

Successful use of a clinical bundle to avoid peri-intubation hypoxia by a non-physician team utilising relaxants in non-arrested adults has been reported [50]. The bundle mandated intubation attempts be abandoned in favour of mask ventilation and urgent transport when pre-oxygenation failed to achieve a SpO2 of at least 94%. The complete bundle reduced peri-intubation hypoxia rates from 44.2 to 3.5% and suggests that avoiding prehospital intubation in hypoxic patients may minimise risk for teams with lower experience levels. This approach however also potentially denies intubation to patients with critical hypoxia who are arguably the most likely to benefit from early intubation. A focus on oxygenation rather than procedural success is suggested for future studies given this is the primary aim of all airway management. It is noteworthy that in our systematic review, only six studies could be identified that reported hypoxia as an outcome from 40 studies that met the inclusion criteria.

Caution is also needed in interpreting our meta-analysis subgroup analysis results as these are observational in nature. However, we believe that the results of the within-study comparisons of different team composition performances in four studies [8, 28, 32, 38], together with insights from our recent study [7], are credible and supportive of higher overall intubation success, first-pass success, and lower complication rates associated with physician teams. Our results were also robust when sensitivity analysis and meta-regressions were performed. The definition of paediatric age group varied between studies ranging from < 13 to < 19 years. Inclusion of a large proportion of teenage patients in a sample is unlikely to reflect the specific issues of paediatric airway management as the greatest difficulty and complication rates occur in smaller children.

Differences in airway training between studies and between team types are a possible explanation for the observed performance differences. As a major difference between physicians and non-physicians is the training programmes to which they have been exposed, it is intuitive to suggest that further training of non-physician teams may decrease or eliminate the observed differences. Reporting of airway training was too heterogeneous to support an analysis however. Some studies provided no description of training [19, 21, 24, 26, 39, 44, 45], and some reported pooled data from multiple agencies [3, 28, 32], whilst others described the studied teams simply as Advanced Life Support and/or Paediatric Advanced Life Support certified [5, 20, 33,34,35].

It is possible that there is variability between team types in willingness to report complications. Studies have demonstrated under-reporting of prehospital intubation complications by non-physician personnel [51] and physician teams [7] when documentation is compared with electronic monitor data. Similarly, under-reporting has been documented in the emergency department setting when video recordings of the resuscitation are reviewed [52]. We are not aware of any studies that compare the rates of under-reporting between team types however. Under-reporting is also likely to be affected by factors such as organisational and national cultures which may confound any difference by team type as well as the status of legal protection for disclosure of complications in the reporting jurisdiction. Ideally, future studies should report complications based on monitor data and/or video review.

Conclusions

Our systematic review supports higher overall success and first-pass success with lower complication rates by teams incorporating physicians when intubating children in the prehospital environment. The results of the meta-analysis suggest that this applies regardless of non-physician team utilisation of neuromuscular blockade. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. 1.

    Eich C, Roessler M, Nemeth M, Russo SG, Heuer JF, Timmermann A. Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians. Resuscitation. 2009;80:1371–7.

    PubMed  Article  Google Scholar 

  2. 2.

    Nagele P, Kroesen G. Pediatric emergencies. An epidemiologic study of mobile care units in Innsbruck. Anaesthesist. 2000;49:725–31.

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    Carlson JN, Gannon E, Mann N, et al. Pediatric out-of-hospital critical procedures in the United States. Pediatr Crit Care Med. 2015;16:e260–7.

    PubMed  Article  Google Scholar 

  4. 4.

    Richard J, Osmond MH, Nesbitt L, Stiell IG. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. Can J Emerg Med. 2006;8:6–12.

    Google Scholar 

  5. 5.

    Garza AG, Algren DA, Gratton MC, Ma OJ. Populations at risk for intubation nonattempt and failure in the prehospital setting. Prehosp Emerg Care. 2005;9:163–6.

    PubMed  Article  Google Scholar 

  6. 6.

    Bankole S, Asuncion A, Ross S, et al. First responder performance in pediatric trauma: a comparison with an adult cohort. Pediatr Crit Care Med. 2011;12:e166–70.

    PubMed  Article  Google Scholar 

  7. 7.

    Garner AA, Bennett N, Weatherall A, Lee A. Physician-staffed helicopter emergency medical services augment ground ambulance paediatric airway management in urban areas: a retrospective cohort study. Emerg Med J. 2019;36:678–83.

    PubMed  Article  Google Scholar 

  8. 8.

    Gerritse BM, Schalkwijk A, Pelzer BJ, Scheffer GJ, Draaisma JM. Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service. BMC Emerg Med. 2010;10:6.

    PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Schmidt AR, Ulrich L, Seifert B, Albrecht R, Spahn DR, Stein P. Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis. Scand J Trauma Resusc Emerg Med. 2016;24:22.

    PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Burns BJ, Watterson JB, Ware S, Regan L, Reid C. Analysis of out-of-hospital pediatric intubation by an Australian helicopter emergency medical service. Ann Emerg Med. 2017;70:773–82.

    PubMed  Article  Google Scholar 

  11. 11.

    Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician out-of-hospital rapid sequence intubation success and adverse events: a systematic review and meta-analysis. Ann Emerg Med. 2017;70:449–59.

    PubMed  Article  Google Scholar 

  13. 13.

    Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health. 2014;72:39.

    PubMed  PubMed Central  Article  Google Scholar 

  14. 14.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Tanner-Smith EE, Tipton E. Robust variance estimation with dependent effect sizes: practical considerations including a software tutorial in Stata and SPSS. Res Synth Methods. 2014;5:13–30.

    PubMed  Article  Google Scholar 

  16. 16.

    Hunter JP, Saratzis A, Sutton AJ, Boucher RH, Sayers RD, Bown MJ. In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias. J Clin Epidemiol. 2014;67:897–903.

    Article  Google Scholar 

  17. 17.

    Aijian P, Tsai A, Knopp R, et al. Endotracheal intubation of pediatric patients by paramedics. Ann Emerg Med. 1989;18:489–94.

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Andrew E, de Wit A, Meadley B, Cox S, Bernard S, Smith K. Characteristics of patients transported by a paramedic-staffed helicopter emergency medical service in Victoria, Australia. Prehosp Emerg Care. 2015;19:416–24.

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Babl F, Vinci R, Bauchner H, Mottley L. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care. 2001;17:5–9.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Baker T, King W, Soto W, Asher C, Stolfi A, Rowin M. The efficacy of pediatric advanced life support training in emergency medical service providers. Pediatr Emerg Care. 2009;25:508–12.

    PubMed  Article  Google Scholar 

  21. 21.

    Boswell W, McElveen N, Sharp M, Boyd C, Frantz E. Analysis of prehospital pediatric and adult intubation. Air Med J. 1995;14:125–8.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    Brownstein D, Shugerman R, Cummings P, Rivara F, Copass M. Prehospital endotracheal intubation of children by paramedics. Ann Emerg Med. 1996;28:34–9.

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Burton J, Baumann M, Maoz T, Bradshaw J, Lebrun J. Endotracheal intubation in a rural EMS state: procedure utilisation and impact of skills maintenance guidelines. Prehosp Emerg Care. 2003;7:352–6.

    PubMed  Article  Google Scholar 

  24. 24.

    Demaret P, Lebrun F, Devos P, et al. Pediatric pre-hospital emergencies in Belgium: a 2-year national descriptive study. Eur J Pediatr. 2016;175:921–30.

    PubMed  Article  Google Scholar 

  25. 25.

    Dyson K, Bray J, Smith K, et al. Paramedic intubation experience is associated with successful tube placement but not cardiac arrest survival. Ann Emerg Med. 2017;70:382–90.

    PubMed  Article  Google Scholar 

  26. 26.

    Ehrlich P, Seidman P, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39:1376–80.

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283:783–90.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Hansen M, Lambert W, Guise J, Warden C, Mann N, Wang H. Out-of-hospital pediatric airway management in the United States. Resuscitation. 2015;90:104–10.

    PubMed  PubMed Central  Article  Google Scholar 

  29. 29.

    Hansen M, Eriksson C, Skarica B, Meckler G, Guise JM. Safety events in pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2018;36:380–3.

    PubMed  Article  Google Scholar 

  30. 30.

    Harrison T, Thomas S, Wedel S. Success rates of pediatric intubation by a non-physician-staffed critical care transport service. Pediatr Emerg Care. 2004;20:101–7.

    PubMed  Article  Google Scholar 

  31. 31.

    Heschl S, Meadley B, Andrew E, Butt W, Bernard S, Smith K. Efficacy of pre-hospital rapid sequence intubation in paediatric traumatic brain injury: a 9-year observational study. Injury. 2018;49:916–20.

    PubMed  Article  Google Scholar 

  32. 32.

    Jarvis JL, Wampler D, Wang HE. Association of patient age with first pass success in out-of-hospital advanced airway management. Resuscitation. 2019;141:136–43.

    PubMed  Article  Google Scholar 

  33. 33.

    Kumar V, Bachman D, Kiskaddon R. Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital setting? Ann Emerg Med. 1997;29:743–7.

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Lavery R, Tortella B, Griffin C. The prehospital treatment of pediatric trauma. Pediatr Emerg Care. 1992;8:9–12.

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Losek JD, Bonadio WA, Walsh-Kelly C, Hennes H, Smith DS, Glaeser PW. Prehospital pediatric endotracheal intubation performance review. Pediatr Emerg Care. 1989;5:1–4.

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Losek JD, Szewczuga D, Glaeser PW. Improved prehospital pediatric ALS care after an EMT-paramedic clinical training course. Am J Emerg Med. 1994;12:429–32.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Martinon C, Duracher C, Blanot S, et al. Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines. Pediatr Crit Care Med. 2011;12:65–70.

    PubMed  Article  Google Scholar 

  38. 38.

    Moors XRJ, Rijs K, Den Hartog D, Stolker RJ. Pediatric out-of-hospital cardiopulmonary resuscitation by helicopter emergency medical service, does it has added value compared to regular emergency medical service? Eur J Trauma Emerg Surg. 2018;44:407–10.

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Nakayama D, Gardner M, Rowe M. Emergency endotracheal intubation in pediatric trauma. Ann Surg. 1990;211:218–33.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  40. 40.

    Nevin D, Green S, Weaver A, Lockey D. An observational study of paediatric pre-hospital intubation and anaesthesia in 1933 children attended by a physician-led, pre-hospital trauma service. Resuscitation. 2014;85:189–95.

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Paul T, Marias M, Pons P, Pons K, Moore E. Adult versus pediatric prehospital trauma care: is there a difference? J Trauma. 1999;47:455–9.

    CAS  PubMed  Article  Google Scholar 

  42. 42.

    Pointer JE. Clinical characteristics of paramedics’ performance of pediatric endotracheal intubation. Am J Emerg Med. 1989;7:364–6.

    CAS  PubMed  Article  Google Scholar 

  43. 43.

    Prekker M, Delgado F, Shin J, et al. Pediatric intubation by paramedics in a large emergency medical services system: process, challenges, and outcomes. Ann Emerg Med. 2016;67:20–9.

    PubMed  Article  Google Scholar 

  44. 44.

    Simons T, Söderlund T, Handolin L. Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study. Eur J Trauma Emerg Surg. 2017;43:797–804.

    CAS  PubMed  Article  Google Scholar 

  45. 45.

    Sing R, Reilly P, Rotondo M, Lynch M, McCans J, Schwab C. Out-of-hospital rapid-sequence induction for intubation of the pediatric patient. Acad Emerg Med. 1996;3:41–5.

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Tarpgaard M, Hansen TM, Rognås L. Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study. Scand J Trauma Resusc Emerg Med. 2015;23:61.

    PubMed  PubMed Central  Article  Google Scholar 

  47. 47.

    Tollefsen WW, Brown CA, Cox KL, Walls RM. Two hundred sixty pediatric emergency airway encounters by air transport personnel: a report of the air transport emergency airway management (NEAR VI: “A-TEAM”) project. Pediatr Emerg Care. 2013;29:963–8.

    PubMed  Article  Google Scholar 

  48. 48.

    Vilke G, Steen P, Smith A, Chan T. Out-of-hospital pediatric intubation by paramedics: the San Diego experience. J Emerg Med. 2002;22:71–4.

    PubMed  Article  Google Scholar 

  49. 49.

    Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017;21:31.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  50. 50.

    Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a clinical bundle to reduce out-of-hospital peri-intubation hypoxia. Ann Emerg Med. 2018;72:272–9.

    PubMed  Article  Google Scholar 

  51. 51.

    Walker RG, White LJ, Whitmore GN, et al. Evaluation of physiologic alterations during prehospital paramedic-performed rapid sequence intubation. Prehosp Emerg Care. 2018;22:300–11.

    PubMed  Article  Google Scholar 

  52. 52.

    Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012;60:251–9.

    PubMed  PubMed Central  Article  Google Scholar 

Download references

Acknowledgements

We thank the staff at Nepean Hospital, Sydney, for their help with the electronic database searches for the systematic review.

Funding

This study was supported by internal funds from CareFlight and the Chinese University of Hong Kong. The funders had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Author information

Affiliations

Authors

Contributions

Conceived the study: A.A.G., A.W., A.L. Designed the protocol: A.A.G., A.W., A.L. Collected the data: A.A.G., N.B., A.W., A.L. Analysed the data: A.A.G., A.L., with input from A. W, N.B. Drafted the manuscript: A.A.G., A.L., revised following critical review by all authors. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Alan A. Garner.

Ethics declarations

Ethics approval and consent to participate

Not applicable to a systematic review.

Consent for publication

Not applicable to a systematic review.

Competing interests

A.L. is an editor for the Cochrane Anaesthesia and the Cochrane Emergency and Critical Care Review Groups and is a member of the editorial board for Perioperative Medicine Journal. All other authors declare no conflicts of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Garner, A.A., Bennett, N., Weatherall, A. et al. Success and complications by team composition for prehospital paediatric intubation: a systematic review and meta-analysis. Crit Care 24, 149 (2020). https://doi.org/10.1186/s13054-020-02865-y

Download citation

Keywords

  • Airway management
  • Child
  • Complications
  • Emergency medical services
  • Intubation