Elsevier

Resuscitation

Volume 81, Issue 2, February 2010, Pages 182-186
Resuscitation

Clinical paper
Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest

https://doi.org/10.1016/j.resuscitation.2009.10.027Get rights and content

Abstract

Background

Clinicians often place high priority on invasive airway placement during cardiopulmonary resuscitation. The benefit of early vs. later invasive airway placement remains unknown. In this study we examined the association between time to invasive airway (TTIA) placement and patient outcomes after inhospital cardiopulmonary arrest (CPA).

Methods

We analyzed data from the National Registry of Cardiopulmonary Resuscitation (NRCPR). We included hospitalized adult patients receiving attempted invasive airway placement (endotracheal intubation, laryngeal mask airway, tracheostomy, and cricothyrotomy) after the onset of CPA. We excluded cases in which airway insertion was attempted after return of spontaneous circulation (ROSC). We defined TTIA as the elapsed time from CPA recognition to accomplishment of an invasive airway. The primary outcomes were ROSC, 24-h survival, and survival to hospital discharge. We used multivariable logistic regression to evaluate the association between the patient outcome and early (<5 min) vs. later (≥5 min) TTIA, adjusted for hospital location, patient age and gender, first documented pulseless ECG rhythm, precipitating etiology and witnessed arrest.

Results

Of 82,649 CPA events, we studied the 25,006 cases in which TTIA was recorded and the inclusion criteria were met. Observations were most commonly excluded for not having an invasive airway emergently placed during resuscitation. The mean time to invasive airway placement was 5.9 min (95% CI: 5.8–6.0). Patient outcomes were: ROSC 50.3% (49.7–51.0%), 24-h survival 33.7% (33.1–34.3%), survival to discharge 15.3% (14.9–15.8%). Early TTIA was not associated with ROSC (adjusted OR: 0.96, 0.91–1.01) but was associated with better odds of 24-h survival (adjusted OR: 0.94, 0.89–0.99). The relationships between TTIA and survival to discharge could not be determined.

Conclusions

Early invasive airway insertion was not associated with ROSC but was associated with slightly improved 24-h survival. Early invasive airway management may or may not improve inhospital cardiopulmonary resuscitation outcomes.

Introduction

Despite ongoing efforts to improve quality of resuscitation care, survival after cardiopulmonary arrest (CPA) remains poor, with fewer than 17% of inhospital arrest and only 8% of out-of-hospital arrest patients surviving to hospital discharge.1, 2, 3 In both inhospital and out-of-hospital settings, practitioners often emphasize early invasive airway placement or endotracheal intubation. The current literature, however, highlights the importance of other concurrent resuscitation actions such as continuous chest compressions and prompt vasoactive drug delivery.4 Most recently, Bobrow et al. noted a significant increase in out-of-hospital cardiac arrest survival using a strategy of minimally interrupted CPR accompanied by delayed endotracheal intubation.5 The relative benefit of early vs. later invasive airway placement remains undefined. A better understanding of this relationship could help to identify the optimal sequence of interventions for resuscitating patients in CPA.

In this study we examined the association between time to invasive airway (TTIA) and outcomes after inhospital CPA.

Section snippets

Methods

The University of Pittsburgh Institutional Review Board approved this study.

We used data from the American Heart Association's National Registry of Cardiopulmonary Resuscitation (NRCPR). Initiated in 2000, the NRCPR is an ongoing, international, multicenter registry of cardiopulmonary arrests (CPA) occurring at facilities in the United States, Canada, and Germany. The registry represents the largest collection of international inhospital CPA events ever compiled, and has provided the basis for

Results

Of the 82,649 events in the dataset we analyzed 25,006 cases meeting study inclusion criteria. Observations were most commonly excluded for not having an invasive airway emergently placed during the resuscitation (n = 40,772). The mean time to invasive airway was 5.9 min (95% CI: 5.8, 6.0). Early airway placement occurred in 10,956 events (43.8%), and later placement occurred in 14,050 (56.2%) (Table 1).

ROSC occurred in 12,590 events (50.3%; 95% CI 49.7%, 51.0%), and 8,413 patients (33.7%;

Discussion

While invasive airway placement is given a high priority in cardiopulmonary resuscitation, our analysis suggests that early compared to later invasive airway placement does not improve odds of ROSC. This observation supports the notion that clinicians may delay – or even defer – invasive airway placement during the initial phases of cardiopulmonary resuscitation without adversely affecting ROSC. While early invasive airway placement is associated with slightly better odds of 24 h survival, the

Conclusion

In this study, early invasive airway insertion was not associated with ROSC but was associated with slightly improved 24-h survival. Early invasive airway management may not improve inhospital cardiopulmonary resuscitation outcomes.

Conflict of interest

None of the authors have financial interests to disclose.

Funding

Mr. Wong is supported by a Medical Student Research Grant jointly administered by the Emergency Medicine Foundation and the Society for Academic Emergency Medicine from Dallas, TX and Lansing, MI, respectively. Mr. Wong is also supported by a research 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.

This research was independent

References (18)

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.10.027.

1

See Appendix 1.

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