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      Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest : A Randomized Clinical Trial

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          Abstract

          Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown.

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          The PRECIS-2 tool: designing trials that are fit for purpose

          K W Loudon, S Treweek, John F Sullivan … (2015)
          Article 0 comments Cited 168 times – based on 0 reviews     Review now
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            Hyperventilation-induced hypotension during cardiopulmonary resuscitation.

            Daniel Sparks, Hertzen von, Scott McKnite … (2004)
            A clinical observational study revealed that rescuers consistently hyperventilated patients during out-of-hospital cardiopulmonary resuscitation (CPR). The objective of this study was to quantify the degree of excessive ventilation in humans and determine if comparable excessive ventilation rates during CPR in animals significantly decrease coronary perfusion pressure and survival. In humans, ventilation rate and duration during CPR was electronically recorded by professional rescuers. In 13 consecutive adults (average age, 63+/-5.8 years) receiving CPR (7 men), average ventilation rate was 30+/-3.2 per minute (range, 15 to 49). Average duration per breath was 1.0+/-0.07 per second. No patient survived. Hemodynamics were studied in 9 pigs in cardiac arrest ventilated in random order with 12, 20, or 30 breaths per minute. Survival rates were then studied in 3 groups of 7 pigs in cardiac arrest that were ventilated at 12 breaths per minute (100% O2), 30 breaths per minute (100% O2), or 30 breaths per minute (5% CO2/95% O2). In animals treated with 12, 20, and 30 breaths per minute, the mean intrathoracic pressure (mm Hg/min) and coronary perfusion pressure (mm Hg) were 7.1+/-0.7, 11.6+/-0.7, 17.5+/-1.0 (P<0.0001), and 23.4+/-1.0, 19.5+/-1.8, and 16.9+/-1.8 (P=0.03), respectively. Survival rates were 6/7, 1/7, and 1/7 with 12, 30, and 30+ CO2 breaths per minute, respectively (P=0.006). Professional rescuers were observed to excessively ventilate patients during out-of-hospital CPR. Subsequent animal studies demonstrated that similar excessive ventilation rates resulted in significantly increased intrathoracic pressure and markedly decreased coronary perfusion pressures and survival rates.
            Article 0 comments Cited 126 times – based on 0 reviews     Review now
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              Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.

              Tom Aufderheide, Keith G Lurie (2004)
              This translational research initiative focused on the physiology of cardiopulmonary resuscitation (CPR) initiated by a clinical observation of consistent hyperventilation by professional rescuers in out-of-hospital cardiac arrest. This observation generated scientific hypotheses that could only ethically be tested in the animal laboratory. To examine the hypothesis that excessive ventilation rates during performance of CPR by overzealous but well-trained rescue personnel causes a significant decrease in coronary perfusion pressure and an increased likelihood of death. In the in vivo human aspect of the study, we set out to objectively and electronically record rate and duration of ventilation during performance of CPR by trained professional rescue personnel in a prospective clinical trial in intubated, adult patients with out-of-hospital cardiac arrest. In the in vivo animal aspect of the study, to simulate the clinically observed hyperventilation, nine pigs in cardiac arrest were ventilated in a random order with 12, 20, or 30 breaths/min, and physiologic variables were assessed. Next, three groups of seven pigs in cardiac arrest were ventilated at 12 breaths/min with 100% oxygen, 30 breaths/min with 100% oxygen, or 30 breaths/min with 5% CO2/95% oxygen, and survival was assessed. Ventilation rate and duration in humans; mean intratracheal pressure, coronary perfusion pressure, and survival rates in animals. In 13 consecutive adults (average age, 63 +/- 5.8 yrs) receiving CPR (seven men) the average ventilation rate was 30 +/- 3.2 breaths/min (range, 15 to 49 breaths/min) and the average duration of each breath was 1.0 +/- 0.07 sec. The average percentage of time in which a positive pressure was recorded in the lungs was 47.3 +/- 4.3%. No patient survived. In animals treated with 12, 20, and 30 breaths/min, the mean intratracheal pressures and coronary perfusion pressures were 7.1 +/- 0.7, 11.6 +/- 0.7, 17.5 +/- 1.0 mm Hg/min (p < .0001) and 23.4 +/- 1.0, 19.5 +/- 1.8, 16.9 +/- 1.8 mm Hg (p = .03) with each of the different ventilation rates, respectively (p = comparison of 12 breaths/min vs. 30 breaths/min for mean intratracheal pressure and coronary perfusion pressure). Survival rates were six of seven, one of seven, and one of seven with 12, 30, and 30 + CO2 breaths/min, respectively (p = .006). Despite seemingly adequate training, professional rescuers consistently hyperventilated patients during out-of-hospital CPR. Subsequent hemodynamic and survival studies in pigs demonstrated that excessive ventilation rates significantly decreased coronary perfusion pressures and survival rates, despite supplemental CO2 to prevent hypocapnia. This translational research initiative demonstrates an inversely proportional relationship between mean intratracheal pressure and coronary perfusion pressure during CPR. Additional education of CPR providers is urgently needed to reduce these newly identified and deadly consequences of hyperventilation during CPR. These findings also have significant implications for interpretation and design of resuscitation research, CPR guidelines, education, the development of biomedical devices, emergency medical services quality assurance, and clinical practice.
              Article 0 comments Cited 96 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Title: JAMA
                Abbreviated Title: JAMA
                Publisher: American Medical Association (AMA)
                ISSN (Print): 0098-7484
                Publication date Created: August 28 2018
                Publication date (Print): August 28 2018
                Volume: 320
                Issue: 8
                Page: 769
                Affiliations
                [1 ]Department of Emergency Medicine, University of Texas Health Science Center at Houston
                [2 ]Department of Emergency Medicine, University of Alabama at Birmingham
                [3 ]Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle
                [4 ]Department of Emergency Medicine, Oregon Health and Science University, Portland
                [5 ]Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
                [6 ]Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, Pennsylvania
                [7 ]University of Pittsburgh, Pittsburgh, Pennsylvania
                [8 ]Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
                [9 ]MedStar Mobile Healthcare, Fort Worth, Texas
                [10 ]currently with Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, Texas
                [11 ]Clackamas Fire District #1, Milwaukie, Oregon
                [12 ]Milwaukee County Office of Emergency Management, Milwaukee, Wisconsin
                [13 ]National Heart, Lung, and Blood Institute, Bethesda, Maryland
                [14 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
                [15 ]Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle
                Article
                DOI: 10.1001/jama.2018.7044
                PMC ID: 6583103
                PubMed ID: 30167699
                SO-VID: 3a691904-abeb-4d99-89d4-37fb62b6f378
                Copyright © © 2018
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