Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?

doi:10.1016/j.resuscitation.2006.06.028

Resuscitation

Volume 72, Issue 2, February 2007, Pages 234-239

https://doi.org/10.1016/j.resuscitation.2006.06.028 Get rights and content

Summary

Background

Out-of-hospital rescuers often perform tracheal intubation (TI) prior to other cardiopulmonary resuscitation (CPR) interventions. TI is a complex and error-prone procedure that may interfere with other key resuscitation tasks. We compared the effects of TI versus esophageal tracheal combitube (ETC) insertion on the accomplishment of other interventions during simulated cardiopulmonary resuscitation.

Methods

In this prospective trial using a human simulator, two-paramedic teams simulated resuscitation of a ventricular fibrillation cardiopulmonary arrest using standard Advanced Cardiac Life Support guidelines. In each of two trials, teams used either TI or ETC as the primary airway device. Following delivery of three rescue shocks, we measured time intervals to successful airway placement, intravenous (IV) line insertion, drug administration, delivery of fourth rescue shock and completion of all four tasks. We also measured the total time without chest compressions. We compared task completion times using non-parametric statistics (Wilcoxon signed-ranks test) with a Bonferroni-adjusted p-value of 0.008.

Results

Twenty teams each completed two scenarios. Participants required a median of 172.5 s (IQR: 146.5–225.5) to accomplish all four tasks. Elapsed time to airway placement was significantly less for ETC than TI (median difference 26.5 s (IQR 13–44.5), p = 0.002). Time without chest compressions was less for ETC than TI (median difference 8.5 s (IQR 2.5–23.5), p = 0.005). There were no differences between ETC and TI in times to IV placement (median difference 23.5 s (IQR −20 to 61), p = 0.11), drug delivery (39.5 s (IQR −18 to 63), p = 0.07), delivery of fourth rescue shock (39.5 s (IQR −21.5 to 87.5), p = 0.07) or completion of all four tasks (33 s (IQR −11 to 74.5), p = 0.08).

Conclusion

Compared with TI, ETC reduced time to airway placement and time without chest compressions, but did not affect elapsed times to accomplish other interventions. Additional time differences may be realized if translated to clinical out-of-hospital conditions.

Introduction

Cardiopulmonary resuscitation is a complex multifaceted process requiring the simultaneous coordination of chest compressions, defibrillation, intravenous drug therapy and airway management, among other tasks.¹ The complexity of resuscitation may distract rescuers, impairing the performance of key interventions.2, 3, 4

Out-of-hospital rescuers often provide airway management using endotracheal intubation (ETI).⁵ Out-of-hospital TI is a complex and error-prone procedure, and in the context of cardiopulmonary resuscitation, has potential to distract and delay the performance of other resuscitation measures.6, 7, 8, 9, 10 Prior efforts have shown that delays in selected interventions (such as chest compressions) may prove lethal.3, 11, 12, 13 Many existing alternate devices exist for providing airway management during resuscitation; for example, the esophageal tracheal combitube (ETC, Kendall Company, Mansfield, MA) and the Laryngeal Mask Airway (LMA, LMA North America, San Diego, CA), among others. While primarily reserved for “rescue” roles in the event of failed TI efforts, these devices are conceptually simpler and may offer ventilation characteristics similar to TI.14, 15, 16, 17, 18, 19, 20, 21, 22, 23 In many countries, paramedics use these as the primary airway device.23, 24

In this study, we compared the effects of TI with ETC on the accomplishment of key interventions during simulated cardiopulmonary resuscitation. We hypothesized that use of the ETC would decrease the elapsed times to accomplish airway placement, establish intravenous access, deliver drugs and administer additional rescue shocks. We also hypothesized that use of the ETC would reduce the amount of time without chest compressions.

Section snippets

Methods and materials

This study was approved by the University of Pittsburgh Institutional Review Board.

In this prospective, randomized trial, paramedics performed the resuscitation of a simulated ventricular fibrillation (VF) cardiopulmonary arrest. Subjects consisted of a convenience sample of paramedics from Emergency Medical Services systems in the Pittsburgh, Pennsylvania region.

Working in two-rescuer teams, subjects completed the study protocol using a human simulator (Advanced Life Support (ALS) Simulator,

Results

Of 42 participants (21 two-rescuer teams), 9 (21%) were female and 33 (79%) were male. Participants had a mean age of 28 ± 5 years and 3 years (range 1–9 years) of paramedic-level experience. Two participants (one team) did not complete the protocol.

Inter-rater agreement of elapsed times was high (Pearson's ρ = 0.99). Teams required a median of 172.5 s (IQR: 146.5–225.5) to accomplish all four tasks (Table 1). Elapsed time to airway placement was lower for ETC than TI (median difference 26.5 s (IQR

Discussion

Cardiopulmonary resuscitation (CPR) is a complex process requiring the coordination of multiple simultaneous tasks. For example, in addition to chest compressions, rescuers must perform airway management, establish vascular access, administer drugs and deliver rescue shocks. Prior studies suggest that the quality of resuscitation interventions may be affected by the complexity of the clinical out-of-hospital environment.2, 3, 4, 32 For example, Rittenberger et al. showed that CPR quality and

Conclusion

Compared with TI, use of ETC reduced the time required to accomplish airway placement and the time without chest compressions during simulated cardiopulmonary resuscitation. The type of airway did not significantly affect the accomplishment of other resuscitation tasks. Additional time differences may be observed if translated to clinical out-of-hospital conditions.

Acknowledgements

This work was supported by a grant from the Pittsburgh Emergency Medicine Foundation (Pittsburgh, PA). Dr. Wang is supported by Clinical Scientist Development Award K08 HS013628 from the Agency for Healthcare Research and Quality (Rockville, MD). The authors thank all participating paramedics and supervisors from Prism Health Services (West Mifflin, PA), Ross/West View EMS (Ross Township, PA), Eastern Area Prehospital Services (Turtle Creek, PA) and Tri-Community South EMS (Bethel Park, PA). We

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Cited by (33)

Type of advanced airway and survival after pediatric out-of-hospital cardiac arrest
2020, Resuscitation
Citation Excerpt :
Thus, skill, proficiency, or experience is necessary for ETI procedure in prehospital AAM in pediatric OHCA. On the other hand, SGA insertion is considered a simpler, quicker, and easier procedure compared with ETI,18–21,48 although to extrapolate from the knowledge based on adult studies may be unreasonable in prehospital AAM in pediatric OHCA. Unfortunately, number of attempts or duration of chest compression interruption was not available from this registry data, but the prehospital ALS time was more prolonged in the ETI group compared with the SGA insertion group in this study (Table 2).
There is a knowledge gap about advanced airway management (AAM) after pediatric out-of-hospital cardiac arrest (OHCA) in the prehospital setting. We assessed which AAM strategy would be associated with an increased chance of survival after pediatric OHCA.
A nationwide population-based observational study was conducted using the Japanese government-led registry data of OHCA. Pediatric OHCA patients (aged 1–17 years) who received prehospital AAM via endotracheal intubation (ETI) or supraglottic airway (SGA) insertion by emergency medical service (EMS) personnel from 2011 to 2017 were included. Patients who received ETI were compared with those who received SGA insertion. The primary outcome was one-month survival after OHCA.
A total of 967 patients (mean [SD] age, 12.2 [5.1] years; 66.6% male) were included; 113 received ETI, and 854 received SGA insertion. Among the total cohort, 118 (12.2%) survived one month after OHCA. In the propensity score-matched cohort, no difference was observed in one-month survival between the ETI and SGA insertion groups: 13 of 113 patients (11.5%) vs 12 of 113 patients (10.6%); RR, 1.08; 95%CI, 0.52–2.27. This lack of association between AAM strategy and survival was observed across a variety of subgroup and sensitivity analyses, and also for neurologically favorable survival (P = 0.5611) in the propensity score-matched analysis.
In Japan, among pediatric OHCA patients, there was no significant difference in one-month survival between prehospital ETI and SGA insertion by EMS personnel. Although an adequately powered randomized controlled trial is needed, EMS personnel may choose their familiar strategy when prehospital AAM was performed during pediatric OHCA.
Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis
2018, American Journal of Emergency Medicine
Citation Excerpt :
In total data from 539,146 patients were included (Table 1). Details on the individual excluded studies are listed in Table S1 [13-48]. Each study was then screened for risk of bias and methodological quality using the Cochrane Collaboration's tool for assessing the risk of bias for RCTs and the ROBINS-I tool for non-randomised studies (Table S2).
To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).
A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.
Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I² = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I² = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I² = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I² = 0%; p < 0.00001).
The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.
Supraglottic airway device placement by respiratory therapists
2018, American Journal of Emergency Medicine
Citation Excerpt :
Since these devices are not meant to enter the trachea, minimal training is required for proper device placement [12]. A major benefit to supraglottic airway device placement though is a decrease in time for CPR interruption [13]. CPR interruptions of any duration reduce blood flow, and interruptions >10 s are associated with decreased mean arterial pressure [4, 8, 10].
Respiratory Therapists (RTs) are some of the first staff to arrive at in-hospital incidents where cardiopulmonary resuscitation (CPR) is needed, yet at some facilities, their ability to intubate is limited by hospital scope of practice. During the intubation process, CPR is often interrupted which could potentially increase the likelihood of adverse patient outcomes. Training RTs to secure the airway using non-intubation methods may reduce or eliminate time for CPR interruptions and allow for earlier continuous/uninterrupted chest compressions.
A pilot study was developed to assess the effectiveness of a new policy for RT scope of practice.
RTs were trained for supraglottic airway device placement prior to procedure initiation. After each device insertion event, RTs completed a written survey. Time between cardiac arrest and device insertion, number of insertion attempts, ease of placement, technical specifications of the device, complications, and survival were compiled and compared between supraglottic airway device and endotracheal tube (ETT) placement.
Procedural information from 23 patients who received a supraglottic airway device during the trial was compared to retrospective data of CPR events requiring intubation from the previous year. Time between initiation of cardiac arrest and advanced airway placement decreased significantly (p < 0.0001) when RTs placed the supraglottic airway device (4.7 min) versus ETT at CPR events the previous year (8.6 min). Device-associated complications were minimal and patient mortality was the same regardless of device.
We propose that more RTs should be trained to insert supraglottic airway devices during inpatient CPR events.
Prehospital endotracheal intubation and survival after out-of-hospital cardiac arrest: Results from the Korean nationwide registry
2016, American Journal of Emergency Medicine
Optimal out-of-hospital cardiac arrest (OHCA) airway management strategies are still controversial. Recent studies reported survival was higher among patients who received bag-valve-mask (BVM) than those receiving endotracheal intubation (ETI) or supraglottic airway (SGA). The aim of this study was to compare neurologically favorable survival outcomes among adult nontraumatic OHCA patients by prehospital airway.
We used the Korean nationwide OHCA cohort database from 2010 to 2013. The inclusion criteria were all OHCA adults with presumed cardiac etiology, resuscitated by level-1 emergency medical technician. Patients were excluded if their information about the method of prehospital airway or clinical outcomes at hospital discharge could not be captured. The primary outcome was neurologically favorable survival to discharge. We compared the outcomes among 3 groups (ETI, SGA, or BVM) by prehospital airway using multivariable logistic regression with interaction model.
Of 98 896 patients with OHCA, 32 513 were included in analysis. Patients receiving BVM were 29 684 and 2829 underwent advanced airway management including 1634 with SGA and 1195 with ETI. The odds of neurologically favorable survival to discharge was significantly higher in the ETI group compared to the BVM group (adjusted OR, 1.405; 95% CI, 1.1001-1.971). In the interaction model by witnessed status, the effect of ETI on good clinical outcomes was shown only in the patients whose arrest was unwitnessed.
In this Korean nationwide, population-based OHCA cohort, neurologically favorable survival to hospital discharge rates was significantly higher among patients who received ETI than those receiving BVM or SGA.
An instrument approach to airway management
2015, Air Medical Journal
Citation Excerpt :
However, there are common barriers to placing an EGA that include but are not limited to perceived value of intubation over an EGA, pressure from colleagues/other providers, and the notion that an unsuccessful intubation is a failure. This is despite a growing body of literature that indicates that persisting in intubation can be detrimental to patient outcome because of time delays,15 hypoxemia,16 cardiopulmonary resuscitation disruption,17 and other problems.18 The literature also points to the high complication rate associated with repeated intubation attempts.19,20
The impact of airway management on quality of cardiopulmonary resuscitation: An observational study in patients during cardiac arrest
2014, Resuscitation
Minimising interruptions in chest compressions is associated with improved survival from cardiac arrest. Current in-hospital guidelines recommend continuous chest compressions after the airway is secured on the premise that this will reduce no flow time. The aim of this study was to determine the effect of advanced airway use on the no flow ratio and other measures of CPR quality.
Consecutive adult patients who sustained an in-hospital cardiac arrest were enrolled in this prospective observational study. The quality of CPR was measured using the Q-CPR device (Phillips, UK) before and after an advanced airway device (endotracheal tube [ET] or laryngeal mask airway [LMA]) was inserted. Patients receiving only bag-mask ventilation were used as the control cohort. The primary outcome was no flow ratio (NFR). Secondary outcomes were chest compression rate, depth, compressions too shallow, compressions with leaning, ventilation rate, inflation time, change in impedance and time required to successfully insert airway device.
One hundred patients were enrolled in the study (2008–2011). Endotracheal tube and LMA placement took similar durations (median 15.8 s (IQR 6.8–19.4) vs LMA median 8.0 s (IQR 5.5–15.9), p = 0.1). The use of an advanced airway was associated with improved no flow ratios (endotracheal tube placement (n = 50) improved NFR from baseline median 0.24 IQR 0.17–0.40) to 0.15 to (IQR 0.09–0.28), p = 0.012; LMA (n = 25) from median 0.28 (IQR 0.23–0.40) to 0.13 (IQR 0.11– 0.19), p = 0.0001). There was no change in NFR in patients managed solely with bag valve mask (BVM) (n = 25) (median 0.29 (IQR 0.18–0.59) vs median 0.26 (IQR 0.12–0.37), p = 0.888). There was no significant difference in time taken to successfully insert the airway device between the two groups.
The use of an advanced airway (ETT or LMA) during in-hospital cardiac arrest was associated with improved no flow ratio. Further studies are required to determine the effect of airway devices on overall patient outcomes.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2006.06.028.

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Clinical paperDoes the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?☆

Summary

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

Acknowledgements

Resuscitation

Resuscitation

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Prehosp Emerg Care

Ann Emerg Med

Ann Emerg Med

Chest

Resuscitation

Resuscitation

Ann Emerg Med

Ann Emerg Med

Am J Med

Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest

JAMA

Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest

JAMA

Clinical paper
Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?☆