Clinical paperTime to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest☆
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)
- et al.
Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation
Resuscitation
(2003) - et al.
Incidence of EMS-treated out-of-hospital cardiac arrest in the United States
Resuscitation
(2004) - et al.
Interruptions of cardiopulmonary resuscitation chest compressions during paramedic endotracheal intubation
Acad Emerg Med
(2008) - et al.
Time to intubation and survival in prehospital cardiac arrest
Prehospital Emerg Care
(2004) - et al.
In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway
Resuscitation
(2003) - et al.
Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest
Resuscitation
(2006) - et al.
Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest
Resuscitation
(2005) - et al.
Regional variation in out-of-hospital cardiac arrest incidence and outcome
JAMA
(2008) Part 7.2: management of cardiac arrest
Circulation
(2005)
Cited by (38)
Association between time to advanced airway management and neurologically favourable survival during out-of-hospital cardiac arrest
2021, Anaesthesia Critical Care and Pain MedicineCitation Excerpt :Thus far, no RCTs have directly investigated the optimal timing of AAM. Although there have been several observational studies on this theme, not only were they limited by high risk of bias and small sample size, but they also showed inconsistent results [18–21]. To address this knowledge gap, we sought to examine the association between the timing of AAM and outcomes after OHCA using huge data from Japan.
Advanced airway management during adult cardiac arrest: A systematic review
2019, ResuscitationA novel technique to assess the quality of ventilation during pre-hospital cardiopulmonary resuscitation
2018, ResuscitationCitation Excerpt :The time to advanced airway management in this study might be affected by whether BLS or paramedics performed initial airway management. In other EMS configurations in which non paramedic emergency personnel place the airway assistance, the time intervals with valve-bag-mask ventilation could be shortened to 5 minutes [28,29]. Transthoracic bioimpedance has been used for cardiac output measurement for more than 100 years.
Timing of advanced airway management by emergency medical services personnel following out-of-hospital cardiac arrest: A population-based cohort study
2018, ResuscitationCitation Excerpt :The discrepancies among the results might be due to the differences of both the frequency of field termination of resuscitation and the frequency of prehospital AAM by EMS personnel in each country. Importantly, however, the previous studies of OHCA did not consider the timing of AAM, although previous studies on IHCA indicated the importance of early timing of AAM [12,13,22,23]. In addition, we considered that characteristics were different between patients with AAM and those with no AAM.
- ☆
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.