Aspirations- und Pneumonierisiko nach präklinischer invasiver Beatmung

Advanced airway management during adult cardiac arrest: A systematic review

AIM

To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations.

METHODS

The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies.

RESULTS

We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses.

CONCLUSIONS

We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.

[Early onset pneumonia after successful resuscitation : Incidence after mild invasive hypothermia therapy]

BACKGROUND

Targeted temperature management (TTM) represents an effective therapy to improve neurologic outcome in patients who survive an out-of-hospital cardiac arrest (OHCA). First publications about this therapy reported a higher incidence of infections in patients who underwent TTM induced by external cooling devices. Whether intravascular cooling devices are also associated with an increased infection rate has not been investigated so far.

METHODS

In a single center retrospective study, the incidence of early onset pneumonia (EOP) in OHCA patients with or without intravascular TTM at 33 °C target temperature for 24 h who survived at least 24 h after admission was analyzed.

RESULTS

A total of 68 OHCA survivors (mean age 65 ± 15 years) were included in this analysis. The most common causes of OHCA were myocardial infarction (35 %), primary ventricular fibrillation (24 %), asystole (15 %), and pulmonary embolism (7 %). Of those, 32 patients (48 %) received TTM. The overall incidence of EOP was 38 %. Incidence of EOP did not differ significantly between groups, was more frequent in the group without TTM (42 % vs. 34 %, p = 0.57) and had no impact on mortality (hazard ratio = 1.02; 95 % confidence interval 0.25-4.16; p = 0.97).

CONCLUSION

Intravascular TTM at 33 °C with a cooling catheter is not associated with more infective complications in OHCA patients. This finding underscores the safety of TTM.

Early-Onset Pneumonia in Non-Traumatic Out-of-Hospital Cardiac Arrest Patients with Special Focus on Prehospital Airway Management

Background

More than half of all non-traumatic out-of-hospital cardiac arrest (OHCA) patients die in the hospital. Early-onset pneumonia (EOP) has been described as one of the most common complications after successful cardiopulmonary resuscitation. However, the expanded use of alternative airway devices (AAD) might influence the incidence of EOP following OHCA.

Material/Methods

We analyzed data from all OHCA patients admitted to our hospital between 1 January 2008 and 31 December 2014. EOP was defined as proof of the presence of a pathogenic microorganism in samples of respiratory secretions within the first 5 days after hospital admission.

Results

There were 252 patients admitted: 155 men (61.5%) and 97 women (38.5%), with a mean age of 69.1±13.8 years. Of these, 164 patients (77.6%) were admitted with an endotracheal tube (ET) and 62 (27.4%) with an AAD. We found that 36 out of a total of 80 respiratory secretion samples (45.0%) contained pathogenic microorganisms, with Staphylococcus aureus as the most common bacteria. Neither bacterial detection (p=0.765) nor survival rates (p=0.538) differed between patients admitted with ET and those with AAD.

Conclusions

Irrespective of increasing use of AAD, the incidence of EOP remains high.

[Preclinical duty of care during cuff pressure management]

BACKGROUND

Airway morbidity is influenced by different factors. Independent of the main emergency health problem, airway morbidity factors may exacerbate a possible poor outcome (e.g., bleeding, tongue swelling, nerve lesion).

OBJECTIVES

However, insertion technique and cuff pressure management are both important for duty of care out-of-hospital emergency medicine. After securing the airway (e.g., tracheal tube or supraglottic airway device cuff), pressure measurement is necessary.

MATERIALS AND METHODS

In a number of recent publications, a largely forgotten issue has come into the focus of preclinical science. This issue became particularly relevant in the admitting hospital.

RESULTS

The results from the aforementioned publications show that preclinical management of cuff pressure is not taken sufficiently into consideration, resulting in possible harm to the patient.

DISCUSSION

It is important and safe to use a cuff pressure device. The initial cuff pressure and if necessary corrected value should be documented.

Effect of the laryngeal tube on the no-flow-time in a simulated two rescuer basic life support setting with inexperienced users

INTRODUCTION

Intubation with a laryngeal tube (LT) is a recommended alternative to endotracheal intubation during advanced life support (ALS). LT insertion is easy; therefore, it may also be an alternative to bag-mask ventilation (BMV) for untrained personnel performing basic life support (BLS). Data from manikin studies support the influence of LT on no-flow-time (NFT) during ALS.

METHODS

We performed a prospective, randomized manikin study using a two-rescuer model to compare the effects of ventilation using a LT and BMV on NFT during BLS. Participants were trained in BMV and were inexperienced in the use of a LT.

RESULTS

There was no significant difference in total NFT with the use of a LT and BMV (LT: mean 83.1 ± 37.3 s; BMV: mean 78.7 ± 24.5 s; p = 0.313), but we found significant differences in the progression of the scenario: in the BLS-scenario, the proportion of time spent performing chest compressions was higher when BMV was used compared to when a LT was used. The quality of chest compressions and the ventilation rate did not differ significantly between the two groups. The mean tidal volume and mean minute volume were significantly larger with the use of a LT compared with the use of BMV.

CONCLUSIONS

In conclusion, in a two-rescuer BLS scenario, NFT is longer with the use of a LT (without prior training) than with the use of BMV (with prior training). The probable reasons for this result are higher tidal volumes with the use of a LT leading to longer interruptions without chest compressions.