Description: AIRPORT and ELITE trials for EUPHOREA
AIRPORT-trial:
The AIRPORT-trial is a prospective clinical observational study in 21 key international physician manned
Helicopter Emergency Medical Services; to implement, validate and revise a novel Utstein-style template for
uniform reporting of data from prehospital advanced airway management (1). The trial is conducted through
the EUPHOREA research network, and funded by The Norwegian Air Ambulance Foundation.
Project management:
 PhD candidate: Geir Arne Sunde, MD (Project manager)
 Ass. Prof Stephen Sollid, MD, PhD (Project main supervisor)
 Professor David Lockey, MD, PhD
 Ass. Prof Jon-Kenneth Heltne, MD, PhD
Contact: Geir Arne Sunde, Email: geir.arne.sunde@norskluftambulanse.no
Background for AIRPORT
Advanced airway management and ventilatory control is generally regarded as vital in the management of
seriously ill or injured patients (2, 3), and can be critical interventions in patients with out-of-hospital
emergencies. However, interventions like tracheal intubation (TI) suffer from lack of clear evidence of a
beneficial effect (1, 4, 5). Despite the publication of numerous airway management studies, inconsistent and
imprecise reporting of data across heterogenous patient populations and EMS systems persists, and the
questions of how, and by whom, prehospital advanced airway management should be performed remains
disputed (4).
The recognition of tracheal intubation as a “complex intervention” marks the need for an international
standard for documenting and reporting of prehospital intubations in severely injured or ill patients, alongside
a standardization of research data collection to eliminate confounding factors (4, 6, 7). An Utstein-style
template for uniform reporting of data from prehospital advanced airway management has recently been
developed by an international airway management expert group (1). The template proposes a core dataset
constituting five major groups; “Core system variables”, “Core patient variables“, “Core post-intervention
variables”, “Fixed system variables” and “Optional data variables”.
To our knowledge, uniform standards for data reporting have never been implemented for prehospital
advanced airway management across international physician manned EMS services and patient populations.
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Implementing and validating the novel Utstein-style template for prehospital airway management, may result
in a high quality dataset and generate the opportunity for research cooperation and comparison of airway
management practice between EMS systems, contributing new knowledge in this field (1, 4).
The AIRPORT trial aims to describe the characteristics and outcome of advanced prehospital airway
management from international Helicopter Emergency Medical Services that provide the full range of
advanced emergency airway management.
Status for the AIRPORT-trial per August 2013
AIRPORT was planned and ethically approved in 2011, then executed as a prospective clinical observational
study during 2012 and spring of 2013. We enlisted 21 key international physician manned Helicopter
Emergency Medical Services in 6 countries (UK, Australia, Hungary, Finland, Switzerland and Norway), and
collected data according to the template for uniform reporting of data over a 12 month study period. Data
sampling was completed on 15 March 2013, and the AIRPORT trial has included 2335 critically ill or injured
patients, all receiving advanced prehospital airway management from physician manned HEMS. The project is
now entering into the analysis stage, with publication of the first paper planned for late 2013. The trial is
registered in Clinicaltrials.gov: NCT01502111.
Participating centers in AIRPORT:
HEMS-Base
Main coordinators
1.
Norway (7 bases)
Geir Arne Sunde / Stephen Sollid
2.
UK (2 bases)
David Lockey / Richard Lyon
3.
Australia (1 base)
Brian Burns
4.
Finland (3 bases)
Helena Jäntti / Jouni Kurola
5.
Hungary (7 bases)
Akos Soti / Temesvári Péter
6.
Switzerland (1 base)
Falko Harm / Mathias Zuercher
ELITE-trial:
The ELITE trial is a prospective randomized controlled trial (RCT) in physician manned Emergency Medical
Services to compare competent EARLY-intubation to LATE-intubation in patients with on-scene Glasgow
Coma Scale (GCS) < 9 and short ambulance transport times (< 20 min) to hospital. The trial is conducted
through the EUPHOREA research network, and funded by The Norwegian Air Ambulance Foundation.
Project management:
 PhD candidate: Geir Arne Sunde, MD (Project manager)
 PhD candidate: Espen Fevang, MD
 Ass. Prof Stephen Sollid, MD, PhD (Project main supervisor)
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 Professor David Lockey, MD, PhD
 Professor Hans Morten Lossius, MD, PhD
 Ass. Prof Jon-Kenneth Heltne, MD, PhD
 Ass. Prof Jo Røislien, PhD
Contact: Geir Arne Sunde, Email: geir.arne.sunde@norskluftambulanse.no
Background for ELITE
Advanced airway management and ventilatory control is generally regarded as vital in the management of
seriously ill or injured patients, and can be critical interventions in patients with out-of-hospital emergencies (2,
3). However, prehospital interventions like endotracheal intubation (ETI) suffer from lack of clear evidence of a
beneficial effect (1, 4, 5, 8-10). While some evidence indicate that early ETI is associated with increased
mortality and worsened outcome, other studies maintain the benefits of prehospital intubation, e.g. in patients
with severe head trauma, and the evidence still remains conflicting (9, 11-13). A study by Sollid et al
demonstrated a probability as high as 29% of patients arriving in the hospital without ETI, despite a prehospital
indication, and despite being treated by physician manned EMS services capable of delivering competent drugassisted airway interventions (14).
A recent prospective randomized controlled trial on patients with severe traumatic brain injury, comparing
early intubation by paramedics to late intubation by emergency department physicians, showed no differences
in survival to hospital discharge (15). Comparably, both groups had similar admission vital signs and similar
arterial blood gas values. Adversely, the study also showed higher prehospital cardiac arrest rates, higher
prehospital missed intubation rates, longer on-scene times and higher IV-fluid rates in the early intubation
group.
The reported incidence of unanticipated difficult endotracheal intubation is much higher in patients served by
prehospital EMS services than in patients due for in-hospital general anesthesia, and field intubation is
associated with a higher rate of complications compared to in-hospital intubation (8, 16-19). When optimally
performed by competent anesthesia trained providers, including standardization of pharmacological procedure
for intubation and difficult airway management strategy, the incidence of unanticipated difficult prehospital or
emergency intubations are still as high as 6 to 26,9 % (20-22).
Provider competence and experience can be a major determinant in the performance of intubation, both inhospital, like the emergency department, and in the prehospital field (10, 17, 23, 24). To obtain a high degree
of proficiency in advanced airway management skills, and to be able to maintain these skills and perform with a
high probability of success under difficult operating conditions, can be challenging (25, 26). As the Scandinavian
Society for Anaesthesiology and Intensive Care Medicine´s task force on prehospital airway management
stated: “…even for maximally skilled personnel, it should always be considered whether intubation attempts
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should be performed prehospitally or be postponed till more advanced in-hospital techniques are available.
The clinical situation as well as the distance from the hospital will decide the correct treatment in a given case”
(27).
A recent Cochrane review on emergency intubation suggested that there is insufficient high quality data
available to comment on the efficacy of emergency endotracheal intubation (ETI) (28). Other studies also
endorse further prospective randomized trials looking at prehospital advanced airway management (5, 29, 30).
Very few comparable studies have been done in physician manned EMS services, and no prospective
randomized controlled trials have been performed comparing endotracheal intubation to bag-mask-ventilation
in patients with GCS < 9 and short transport times to hospital.
Status for the ELITE trial per August 2013
The ELITE trial is planned as a prospective randomized controlled trial in several international physician
manned helicopter emergency medical systems. The trial protocol was approved by the Regional Ethics
Committee in Norway in autumn of 2012, and ethical applications are currently being sought in other
participating countries. We are now in the process of recruiting national and international centers for
participation, and plan to start ELITE in the first participating centers within the next few months. The trial is
registered in Clinicaltrials.gov: NCT01730001
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