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

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

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

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

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

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

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

86,628 patients were matched based on the propensity score

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

Kim JW. Resuscitation 2016;105:196–202

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)

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

Resuscitation 2015;93:20–6

Survival to hospital discharge CPC 1-2

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

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

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

jerry.nolan@nhs.net