Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis

Study objective: Rapid sequence intubation performed by nonphysicians such as paramedics or nurses has become increasingly common in many countries; however, concerns have been stated in regard to the safe use and appropriateness of rapid sequence intubation when performed by these health care providers. The aim of our study is to compare rapid sequence intubation success and adverse events between nonphysician and physician in the out-of-hospital setting. Methods: A systematic literature search of key databases including MEDLINE, EMBASE, and the Cochrane Library was conducted. Eligibility, data extraction, and assessment of risk of bias were assessed independently by 2 reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success and for adverse events when possible. Results: Eighty-three studies were included in the meta-analysis. There was a 2% difference in successful intubation proportion for physicians versus nonphysicians, 99% (95% confidence interval [CI] 98% to 99%) versus 97% (95% CI 95% to 99%). A 10% difference in first-pass rapid sequence intubation success was noted between physicians versus nonphysicians, 88% (95% CI 83% to 93%) versus 78% (95% CI 65% to 89%). For airway trauma, bradycardia, cardiac arrest, endobronchial intubation, hypertension, and hypotension, lower prevalences of adverse events were noted for physicians. However, nonphysicians had a lower prevalence of hypoxia and esophageal intubations. Similar proportions were noted for pulmonary aspiration and emesis. Nine adverse events estimates lacked precision, except for endobronchial intubation, and 4 adverse event analyses showed evidence of possible publication bias. Consequently, no reliable evidence exists for differences between physicians and nonphysicians for adverse events. Conclusion: This analysis shows that physicians have a higher rapid sequence intubation first-pass and overall success, as well as mostly lower rates of adverse events for rapid sequence intubation in the out-of-hospital setting. Nevertheless, for all success and adverse events no firm conclusion for a difference could be drawn because of lack of precision of meta-analytic estimates or selective reporting. First-pass success could be an area in which to focus quality improvement strategies for nonphysicians.