Dr. Hoffman is the editor-in-chief of PulmCCM, a blog that frequently updates its readers on evidence and best practices in critical care medicine. I have always wondered how our work in the field affects a patient's care downstream. Do pulmonologists ever sigh to themselves and think, "God, I wish paramedics would just start/stop doing ____________?" Turns out, this is not the case, but the discussion was super interesting and I thank Dr. Hoffman for coming on the show.
Topics Discussed & Summarized Response by Dr.Hoffman
Do ETT tubes placed in the field make the patient more vulnerable to VAP as well as other complications?**
"That's a great question. It’s been a topic of some debate, and the data we have is mixed. Large case series and some randomized trials show that in specific populations, like traumatic brain injury patients, the risk of ventilator-associated pneumonia (VAP) isn’t significantly higher when intubation happens in the field. That said, complications tied directly to intubation in the field—like aspiration—tend to be more common due to the conditions EMS providers work under compared to the controlled environment of a hospital. Ultimately, it comes down to how well the situation is managed in the moment. If you’re providing excellent care with proper precautions, you’re doing the best you can to minimize those risks."
How important are cuff pressures in the prehospital setting?
"Cuff pressures are an important consideration, but in the field, you’re often operating in a time-sensitive, high-stakes environment. While you want to avoid under- or over-inflation, which could lead to complications like aspiration or tracheal injury, precise measurement might not always be feasible. The goal is to balance the immediate need to secure the airway with the longer-term consequences, knowing that adjustments can be fine-tuned later in the hospital."
Are there any specific airway management techniques or ventilatory support settings you wish were more commonly practiced or avoided by EMS?
"I’d say that EMS providers already do a phenomenal job managing complex airways in challenging conditions. If anything, I’d encourage leaning into pre-oxygenation and focusing on avoiding hypoxemia and hypotension during intubation. Another key piece is ventilator management—sometimes patients arrive with overly generic vent settings that don’t match their clinical situation. Optimizing settings, especially in terms of tidal volume and PEEP, can make a big difference during transport."
When a critical care team transports a patient from an outlying ER to your ICU, do you automatically set your own ventilator settings, or do you ever use the vent settings the critical care transport team had dialed in for transport?
"That’s an interesting point. In most hospitals I’ve worked at, ventilator protocols tend to take over as soon as the patient arrives in the ICU. That said, if the settings provided during transport are working well, we might use them as a starting point. However, we’ll almost always adjust based on the patient’s current needs, labs, and imaging. The key is ensuring the patient gets individualized care based on their unique physiology."
Some EMS providers like to use Ketamine drips for sedation during transport. How often is this continued at the receiving hospital? Is there any downside or upside to EMS using Ketamine in this way? We don’t seem to see Ketamine infusions in the ICU often. Why is that?
"Ketamine is definitely a tool that has its place. In the ICU, it’s often used as a third- or fourth-line sedative, especially for agitated patients or those with a psychiatric history. While it’s not as common as fentanyl, propofol, or dexmedetomidine, it’s gaining traction in some systems. One upside to using it in the field is that it doesn’t cause the hypotension you often see with other sedatives. On the downside, long-term data on continuous ketamine use is limited, and there’s some variability in its adoption based on the culture of individual hospitals. If a patient comes in on a ketamine drip, we’re likely to assess their overall stability and might transition them to another sedative depending on their needs."
References
Amer, M., Maghrabi, K., Bawazeer, M., et al. (2021). Adjunctive ketamine for sedation in critically ill mechanically ventilated patients: An active-controlled, pilot, feasibility clinical trial. Journal of Intensive Care, 9, 54. https://doi.org/10.1186/s40560-021-00569-1
Arumugam, S. K., Mudali, I., Strandvik, G., El-Menyar, A., Al-Hassani, A., & Al-Thani, H. (2018). Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis. World Journal of Emergency Medicine, 9(3), 203–210. https://doi.org/10.5847/wjem.j.1920-8642.2018.03.007
Gianakis, A., McNett, M., Belle, J., Moran, C., & Grimm, D. (2015). Risk factors for ventilator-associated pneumonia: Among trauma patients with and without brain injury. Journal of Trauma Nursing: The Official Journal of the Society of Trauma Nurses, 22(3), 125–131. https://doi.org/10.1097/JTN.0000000000000121
Kumar, C. M., Seet, E., & Van Zundert, T. C. R. V. (2021). Measuring endotracheal tube intracuff pressure: No room for complacency. Journal of Clinical Monitoring and Computing, 35(1), 3–10. https://doi.org/10.1007/s10877-020-00501-2
Tennyson, J., Ford-Webb, T., Weisberg, S., & LeBlanc, D. (2016). Endotracheal tube cuff pressures in patients intubated prior to helicopter EMS transport. The Western Journal of Emergency Medicine, 17(6), 721–725. https://doi.org/10.5811/westjem.2016.8.30639
Umunna, B. P., Tekwani, K., Barounis, D., Kettaneh, N., & Kulstad, E. (2015). Ketamine for continuous sedation of mechanically ventilated patients. Journal of Emergencies, Trauma, and Shock, 8(1), 11–15. https://doi.org/10.4103/0974-2700.145414
Zygun, D. A., Zuege, D. J., Boiteau, P. J., Laupland, K. B., Henderson, E. A., Kortbeek, J. B., & Doig, C. J. (2006). Ventilator-associated pneumonia in severe traumatic brain injury. Neurocritical Care, 5(2), 108–114. https://doi.org/10.1385/NCC:5:2:108
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