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Wang HE. Prehospital Airway Management - the Continued Search for Evidence. PREHOSP EMERG CARE 2023; 28:558-560. [PMID: 38133521 DOI: 10.1080/10903127.2023.2281361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Henry E Wang
- Department Emergency Medicine, The Ohio State University, Columbus, Ohio
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Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation 2023; 148:1847-1856. [PMID: 37952192 PMCID: PMC10840971 DOI: 10.1161/circulationaha.123.065561] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/28/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest. METHODS We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2). RESULTS Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders. CONCLUSIONS In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.
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Affiliation(s)
- Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | | | - Brian Leroux
- Department of Biostatistics (B.L., J.C.), University of Washington, Seattle
| | - Xabier Jaureguibeitia
- Department of Communications Engineering, University of the Basque Country, Bilbao, Spain (E.A.E., X.J.)
| | - Betty Y Yang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Sarah Shaver
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Mary P Chang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I, B.Y.Y., S.S., M.P.C.)
| | - Tom Rea
- Department of Medicine (Emergency Medicine) (T.R.), University of Washington, Seattle
| | - Peter Kudenchuk
- Department of Medicine (Cardiology) (P.K.), University of Washington, Seattle
| | - Jim Christenson
- Department of Biostatistics (B.L., J.C.), University of Washington, Seattle
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (J.C.)
| | | | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, PA (C.C., D.S.)
| | - David Salcido
- Department of Emergency Medicine, University of Pittsburgh, PA (C.C., D.S.)
| | | | - Jennifer Blackwood
- Public Health-Seattle & King County, Emergency Medical Services Division, Seattle, WA (J.B.)
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus (H.E.W.)
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Methods for calculating ventilation rates during resuscitation from out-of-hospital cardiac arrest. Resuscitation 2023; 184:109679. [PMID: 36572374 DOI: 10.1016/j.resuscitation.2022.109679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Ventilation control is important during resuscitation from out-of-hospital cardiac arrest (OHCA). We compared different methods for calculating ventilation rates (VR) during OHCA. METHODS We analyzed data from the Pragmatic Airway Resuscitation Trial, identifying ventilations through capnogram recordings. We determined VR by: 1) counting the number of breaths within a time epoch ("counted" VR), and 2) calculating the mean of the inverse of measured time between breaths within a time epoch ("measured" VR). We repeated the VR estimates using different time epochs (10, 20, 30, 60 sec). We defined hypo- and hyperventilation as VR <6 and >12 breaths/min, respectively. We assessed differences in estimated hypo- and hyperventilation with each VR measurement technique. RESULTS Of 3,004 patients, data were available for 1,010. With the counted method, total hypoventilation increased with longer time epochs ([10-s epoch: 75 sec hypoventilation] to [60-s epoch: 97 sec hypoventilation]). However, with the measured method, total hypoventilation decreased with longer time epochs ([10-s epoch: 223 sec hypoventilation] to [60-s epoch: 150 sec hypoventilation]). With the counted method, the total duration of hyperventilation decreased with longer time epochs ([10-s epochs: 35 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). With the measured method, total hyperventilation decreased with longer time epochs ([10-s epoch: 78 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). Differences between the measured and counted estimates were smallest with a 60-s time epoch. CONCLUSIONS Quantifications of hypo- and hyperventilation vary with the applied measurement methods. Measurement methods are important when characterizing ventilation rates in OHCA.
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Measuring ventilation during out-of-hospital cardiac arrest: PART of the equation. Resuscitation 2023; 184:109696. [PMID: 36681381 DOI: 10.1016/j.resuscitation.2023.109696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
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Benoit JL, Lakshmanan S, Farmer SJ, Sun Q, Gray JJ, Sams W, Tadesse DG, McMullan JT. Ventilation rates measured by capnography during out-of-hospital cardiac arrest resuscitations and their association with return of spontaneous circulation. Resuscitation 2023; 182:109662. [PMID: 36481240 DOI: 10.1016/j.resuscitation.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical guidelines for adult out-of-hospital cardiac arrest (OHCA) recommend a ventilation rate of 8-10 per minute yet acknowledge that few data exist to guide recommendations. The goal of this study was to evaluate the utility of continuous capnography to measure ventilation rates and the association with return of spontaneous circulation (ROSC). METHODS This was a retrospective observational cohort study. We included all OHCA during a two-year period and excluded traumatic and pediatric patients. Ventilations were recorded using non-invasive continuous capnography. Blinded medically trained team members manually annotated all ventilations. Four techniques were used to analyze ventilation rate. The primary outcome was sustained prehospital ROSC. Secondary outcomes were vital status at the end of prehospital care and survival to hospital admission. Univariable and multivariable logistic regression models were constructed. RESULTS A total of 790 OHCA were analyzed. Only 386 (49%) had useable capnography data. After applying inclusion and exclusion criteria, the final study cohort was 314 patients. The median ventilation rate per minute was 7 (IQR 5.4-8.5). Only 70 (22%) received a guideline-compliant ventilation rate of 8-10 per minute. Sixty-two (20%) achieved the primary outcome. No statistically significant associations were observed between any of the ventilation parameters and patient outcomes in both univariable and multivariable logistic regression models. CONCLUSIONS We failed to detect an association between intra-arrest ventilation rates measured by continuous capnography and proximal patient outcomes after OHCA. Capnography has poor reliability as a measure of ventilation rate. Achieving guideline-compliant ventilation rates remains challenging.
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Affiliation(s)
- Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Shyam Lakshmanan
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Sam J Farmer
- University of Kentucky College of Medicine - Northern Kentucky Campus, Highland Heights, KY, USA.
| | - Qin Sun
- Data Management and Analysis Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - J Jordan Gray
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Woodrow Sams
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | | | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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