Airway management… not again! - Resus · Airway management during CPR: Summary No high-quality...
34
Airway management… not again! Jerry Nolan Royal United Hospital, Bath, UK
Transcript of Airway management… not again! - Resus · Airway management during CPR: Summary No high-quality...
Airway management… not again!
Jerry Nolan Royal United Hospital, Bath, UK
Conflicts of interest
Editor-in-Chief Resuscitation Co-investigator for
AIRWAYS-2 trial
Airway management during CPR
Objectives of airway management during CPR Tracheal intubation – pros and cons Supraglottic airways Existing evidence Ongoing trials
Objectives of airway management during CPR
Improve ROSC and long-term survival Enable oxygenation and ventilation despite
potentially poor lung compliance (continuous chest compressions)
Protect against aspiration Minimise ‘no flow’ time Minimise complications
Tracheal intubation during CPR: advantages
Enables uninterrupted chest compressions
Enables most effective ventilation? Least likely airway to be
dislodged? Minimises gastric inflation Protects against aspiration
The intubation learning curve
21 first-year anaesthesia residents, Heidelberg, Germany
Bernhard M. Acta Anaesthesiol Scand 2012;56:164-71
Presenter
Presentation Notes
This is the chart for the first attempt Heidelberg, Germany
13 studies; total of 1462 students; attempting to intubate 19,108 patients
In elective setting: at least 50 intubations with no more that two attempts to achieve success rate of 90%.
Heterogeneous data – likely many more required in non-elective settings
Resuscitation 2016;99:63–71
Presenter
Presentation Notes
We identified 13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts need to be performed to reach a success rate of at least 90%. However, the evidence is heterogeneous, and the incidence of difficult airways in non-elective settings is up to 20 times higher compared to elective settings. Taking this factor into account, training should include a variety of exposures and should probably exceed 50 ETIs to successfully serve the most vulnerable patients.
Intubation success: cardiac arrest Study N Intubator Success (%)
Bradley, 1998 57 EMT 49 Sayre, 1998 103 EMT 51 Rumball, 2004 250 EMT 70 Rabitsch, 2003 83 Physician 94 Stiell, 2004 3848 Paramedic 93.7 Deakin, 2010 368 Paramedic 83.8 Lyon, 2010 628 Paramedic 91.2 Stiell, 2011 (ROC) 7651 EMS 89.3 Nichol 2015 (ROC) 13623 EMS 84.3
Presenter
Presentation Notes
Intubation success rate very variable. In Sayre’s study the EMT received just 10 hours intubation training and had to undertake 10 intubations in manikins. In Stiell’s study the ALS component (including intubation) comprised 6 weeks didactic training, 6 weeks clinical instruction and 12 weeks preceptorship training in the field – communities were excluded from the study if intubation success rates were less than 90%. Hubble meta-analysis 91.2 (88.8–93.1)
Interruptions in CPR from tracheal intubation (United States)
100 cardiac arrests with real-time data collection including audio
1st tracheal intubation–associated CPR interruption = 46.5 s (IQR 23.5 – 73 s; range 7 to 221 s)
One third exceeded 1 min
Wang HE. Ann Emerg Med 2009;54:645-652
Presenter
Presentation Notes
Median of 2 interruptions per cardiac arrest with median total interruption time of 110 secs
Operator dependent++ Interrupts chest compressions Excessive ventilation once
intubated? Does not ‘fail-safe’
Unrecognised oesophageal intubation (2–16%)
Bronchial intubation
Tracheal intubation during CPR: disadvantages
Intubations by paramedics, Hampshire, UK 2007
439 tracheal intubation attempts documented by 269 paramedics
368 (83.8%) documented successful
Intubations 0 1 2 3 4 5 6 7 8 9 10 11 Paramedics 128 76 28 22 7 1 2 1 0 1 2 1
Deakin C. EMJ 2009;26:888-91
Presenter
Presentation Notes
More than 75% performed either none or one intubation in 2007
Ann Emerg Med 2017 online
Ambulance Victoria 2008–2014 769 paramedic attempted intubations in 14,857 patients 9,751 cardiac arrests 3 intubations each per year (IQR 1–6) 95% success rate; 80% on the first attempt (cardiac arrests) 79% of intubations before ROSC
Presenter
Presentation Notes
Well trained intensive care paramedics
Dyson K. Ann Emerg Med 2017 online
JAMA 2017;317:494–506
Get With the Guidelines® - Resuscitation registry 2000–14 108,079 adult patients were included from 668 hospitals 66% intubated within the first 15 min 22.4% survived to hospital discharge Time dependent propensity score + risk set matching
Presenter
Presentation Notes
Same finding in children in a study from the same group
86,628 patients were matched based on the propensity score
Presenter
Presentation Notes
Primary outcome was survival to hospital discharge Possible mechanisms: interruptions to chest compressions, hyperventilation, delaying other interventions, delay in intubation success could result in hypoxia, unrecognised oesophageal intubation
Presenter
Presentation Notes
Subgroup analyses
C-MAC Glidescope McGrath
JAMA 2017;317:483–93
See also Janz DR Crit Care Med 2016;44:1980–87 - multiple VLs – no increase in success
Presenter
Presentation Notes
More life-threatening complications in the V/L group
Kim JW. Resuscitation 2016;105:196–202
Presenter
Presentation Notes
RCT - Korea Experienced intubators (> 50 successful ETIs) Highly experienced intubators (> 80 intubations) Used videoanalysis
Waveform capnography is recommended to confirm & continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment (strong recommendation, low quality evidence).
2015 ERC Guidelines: Waveform capnography must be used for confirming tracheal tube placement and monitoring ventilation rate.
Soar J, Callaway CW et al. Resuscitation 2015;95:e71–e120
Cardiac arrest annual report 2015/16
* Insertion of an advanced airway
i-gel LMA Supreme Laryngeal Tube
Kurz MC. Resuscitation 2016;98:35–40
73.2% 72.4% 76.7% 70.6%
Post adjustment difference in favour of SGA: Pre-airway 2.2% (P=0.046) Post-airway 3.4% (P=0.001)
Presenter
Presentation Notes
Sub-analysis of ROC PRIMED Study Process data collected either by puck on chest of from the impedance changes in defibrillation pads. SGAs = LT, LMA and Combitube
N=649,359 Tracheal tube SGA Bag-mask N 41,972 (6%) 239,550 (37%) 367,837 (57%) CPC 1-2 (1 month) 1.0% 1.1% 2.9% Adjusted OR for good outcome vs. BVM (95% CI)
0.32 (0.29-0.36) 0.32 (0.30-0.33) NA
JAMA 2013;309:257-66
All-Japan Utstein Registry 2005 - 2010
Resuscitation 2015;93:20–6
Presenter
Presentation Notes
Excluded nurse and physician intubators – i.e just EMS personnel
Resuscitation 2015;93:20–6
Survival to hospital discharge CPC 1-2
Presenter
Presentation Notes
Excluded nurse and physician intubators – i.e just EMS personnel Sensitivity model excludes the 6 studies deemed to be of very low quality
171 paramedics randomised and trained 615 cardiac arrests Neurological outcome at 6 months LMAS arm suspended
BJA 2016;116:262–8
Clinical Outcomes Outcome i-gel
n = 232 LMAS
n = 174 Usual
Practice n = 209
P
Admission to hospital %
22.0 17.6 21.0
0.58
Survival to hospital discharge %
10.3 8.0
9.1 0.73
Survival to 90 days %
9.5 6.9 8.6 0.65
Benger J. BJA 2016;116:262–8
Presenter
Presentation Notes
No difference between the three groups
England; June 2015 to June 2017 1,400 UK paramedics randomised to use the i-gel or
tracheal intubation as first advanced airway Planned enrolment: 9000 (90% power; 8 vs 10%) 8000 enrolled 1o outcome: mRS at discharge or 30 d 2o outcomes: ventilation success, aspiration…
Taylor J. Resuscitation 2016;109:25–32 DOI 10.1186/ISRCTN08256118
Presenter
Presentation Notes
Survival to 30 day and mRS will be collected for all patients regardless of their consent status - approved by the Health Research Authority Confidentiality Advisory Group (CAG)
Resuscitation 2016;101:57-64
Cluster-randomised by EMS agency with periodic cross over
3000 subjects 85% power for 4.5%
difference in 72 h survival
Tracheal Intubation vs. Bag-valve-mask Ventilation in Patients With Out-of-Hospital Cardiac Arrest (CAAM STUDY)
RCT Paris Primary outcome 28-day CPC 1-2 Enrollment 2000 March 2015 – April 2017 Arms:
BMV – intubation only after ROSC Tracheal intubation ASAP
ClinicalTrials.gov NCT02327026
Airway and ventilation during CPR
•Stepwise approach according to rescuer/patient: •Compression-only •Mouth-to-mouth •Mouth-to-mask •Bag-mask •Supraglottic airway device (e.g. LMA, i-gel)
•Tracheal tube
Simpler
Complex
Airway management during CPR: Summary
No high-quality evidence for any specific approach to airway and ventilation management for cardiac arrest
Stepwise approach to airway management is common but makes research challenging
Bag-mask versus intubation study (CAAM) completed Two ongoing cluster randomised trials:
Airways-2: i-gel versus tracheal intubation PART: LT versus tracheal intubation
