Airway Management during CPR: Tracheal intubation is better than

supraglottic airway

Jerry Nolan Royal United Hospital Bath, UK

Tracheal intubation during CPR: advantages over SGA Enables uninterrupted chest compressions

and minimises ‘no flow’ time Enables most effective ventilation

particularly when lung compliance is poor. Least likely airway to be dislodged? Minimises gastric inflation and protects

against aspiration Evidence for improved outcome with

tracheal intubation compared with SGA

ALS before and after intubation

Kramer-Johansen J. Resuscitation 2006;48:61-9

Quality of resuscitation before and after tracheal intubation

N = 119 Before intubation

After intubation

Difference (mean %, 95% CI)

Chest compressions (% of time)

39 ± 20% 59 ± 18% 20 (16-24)

Compressions min-1 47 ± 25 71 ± 23 24 (19-29) Ventilations min-1 5.6 ± 3.7 14 ± 5.0 8.7 (7.6-9.8)

Kramer-Johansen J. Resuscitation 2006;48:61-9

Regurgitation and aspiration: out-of-hospital cardiac arrest (OHCA)

Regurgitation occurs in 20-30% of OHCAs Regurgitation associated with odds ratio

of survival of 0.5 (0.28 – 0.89) Early-onset pneumonia in 2/3 of OHCA

patients admitted to ICU

Simons RW. Resuscitation 2007;74:4267-31 Virkkunen I. Acta Anaesthesiol Scand 2007;51:202-5 Perbet S. AJRCCM 2011;184:1048-54

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 Hubble, 2010 +++ All 91.2

Hubble MW. Prehosp Emerg Care 2010;14:377–401

Meta-analysis of prehospital airway techniques in cardiac arrest

Supraglottic airway

Insertion Success (%)

95% CI

Combitube 87.4 77.9 – 93.2 LMA 86.3 60.7 – 96.3 Laryngeal Tube 96.0 41.7 – 99.9 Tracheal intubation 91.1 88.0 – 93.4

Hubble MW. Prehosp Emerg Care 2010;14:515-530 Hubble MW. Prehosp Emerg Care 2010;14:377-401

2012, 20:84

Insertion success in 347 patients

2012, 20:84

Advanced Airway device (n=10,455)

Insertion n (%)

Tracheal tube 8487 (81.2%) Supraglottic airway 1968 (18.8%)

Laryngeal tube 909 (63.0%) Combitube 296 (20.5%)

LMA 239 (16.6%)

Resuscitation 2012;83:1061-6

85% received successful Tracheal Tube or SGA alone

Wang HE. Resuscitation 2012;83:1061-6

Survival to discharge with good neurology: TT 4.7% vs. SGA 3.9%

Tanabe S. J Emerg Med 2013;44:389-97

All Japan 2005 – 2007 Advanced airway devices used in 138,248 of 318,141 cardiac arrests

Resuscitation 2012;83:313-9

Korea

% change carotid flow compared with tracheal tube

Resuscitation 2012;83:1025-30

Just finished recruiting (28 Feb 2013) 184 paramedics randomised and trained 600 cardiac arrests Neurological outcome at 6 months Will inform larger RCT

2013;3:e002467

Tracheal intubation during CPR: advantages over SGA: summary

Minimises ‘no flow’ time Enables most effective ventilation Least likely airway to be dislodged Minimises gastric inflation Improved outcome compared with SGA

Airway management during cardiac arrest

Optimal technique is unknown Likely to depend on the skill of the operator Many cardiac arrests involve multiple

airways Timing may critical, e.g. delay intubation

until after ROSC Must not compromise high-quality CPR Large randomised trial is essential