The Impact of Soiled Airway Management on CPR Quality

April 28, 2022 updated by: Shin Kong Wu Ho-Su Memorial Hospital

Regurgitation is an adverse event common during cardiopulmonary resuscitation (CPR) and occurs in 20%-32% of patients experiencing out-of-hospital cardiac arrest (OHCA). It can impair ventilation, induce aspiration, and decrease survival to hospital discharge. Gastric fluid in the airway obscures the laryngeal view, thereby considerably decreasing the first-pass success of endotracheal intubation (ETI) by paramedics.

A human cadaver study reported that ETI outperforms other airway management devices, such as the i-gel, laryngeal mask, and laryngeal tube, in preventing aspiration when regurgitation occurs during CPR. However, ETI is also associated with multiple and prolonged CPR pauses.Compared with the use of supraglottic airway (SGA) devices, ETI results in more hands-off time during CPR. Recent randomised clinical trials have revealed that airway management with an SGA device provides superior outcomes to those of ETI in patients with OHCA. However, ETI remains the preferred management strategy for an airway affected by regurgitation in patients with OHCA.

Current guidelines focus on the quality of CPR because it is a key determinant of survival in patients with OHCA. However, evidence regarding the impact of regurgitation during ETI on CPR quality is limited. This manikin simulation study assessed CPR quality during ETI in airways with and without regurgitation.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

This is a prospective compare study. 54 EMT-Ps, are involved to evaluate the impact of airway management on CPR quality.

The Study uses SALAD training tool for training. The SALAD training tool include Nasco Intubation CPR manikin, which could vomit by pumping liquid into distal esophagus, and HQCPR feedback machine. Two scenarios were simulated. CPR and ETI in an airway with regurgitation (oropharyngeal regurgitation scenario) and CPR and ETI in an airway without regurgitation (clean airway scenario). All EMT-Ps were randomly assigned to participate initially in one of the scenarios. After all EMT-Ps had finished the first scenario, they switched to the other. Three EMT-Ps formed a resuscitation team and played one of the following roles: airway manager, first compressor, or second compressor. In each scenario, each EMT-P was required to take a turn playing all three roles. During each simulation, the airway manager performed BVM ventilation, and the first and second compressors alternately provided chest compression for every five cycles of CPR, with a compression-to-ventilation ratio of 30:2 .

After the first five cycles of CPR, the airway manager was asked to perform intubation during the ongoing chest compression to minimise intubation-associated interruption of chest compression. If necessary, the airway manager could request a pause of the ongoing chest compression. If intubation was not successful, the airway manager performed BVM ventilation twice and then reattempt intubation. After intubation, the airway manager used the BVM to check the lung distention to confirm successful intubation. Each simulation was ended after successful or failed intubation. Failed intubation was defined as either oesophageal intubation or three unsuccessful attempts.

The primary outcomes was chest compression fraction (CCF). The secondary outcomes was the intubation success rate. Chest compression depth, chest compression rate, and longest interruption time, and intubation time were also recorded.

Each CPR-intubation sequence comprised two segments: a compression segment and a hands-off segment. CCF was defined as the proportion of time spent on chest compression in each CPR-intubation sequence. The longest interruption time was defined as the longest hands-off duration in each sequence. An intubation attempt was defined as the insertion of the laryngoscope blade into the mouth and its subsequent withdrawal from the mouth. Intubation time was defined as the period between the start and the end of an intubation attempt. The time spent checking the endotracheal tube position by manual ventilation through the endotracheal tube was not included in the CPR-intubation sequence.

Two video cameras were setup to record the entire simulation process. Two observers reviewed the video records independently to identify the start and end of each CPR-intubation sequence, any intubation attempts, and the hands-off and compression segments of each sequence. Disagreements were resolved by reaching mutual consensus. The HQCPR application on an Android device recorded chest compression depth, rate, and interruptions (defined as no chest compression [hands off] for >1 s). The data from both the video recording and the HQCPR application were used in subsequent analysis.Continuous data are presented as medians with interquartile ranges, and categorical data are presented as frequency counts and percentages. The continuous data were compared using the Wilcoxon rank sum test in the first CPR-intubation sequence and the Mann-Whitney U test in the second and third sequences. The McNemar test was used to compare the intubation success rate in the first sequence, and Pearson's chi-square test was used for the second and third sequences. The continuous data from all three CPR-intubation sequences were compared using the Kruskal-Wallis test. Post hoc analysis was performed using Conover's test.

The association of CPR quality metrics with successful intubation was evaluated using a Cox proportional hazards regression model. The results of multivariate analyses are presented as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). A two-tailed P <0.05 indicates statistical significance. MedCalc Statistical Software version 19.2. (MedCalc Software, Ostend, Belgium) was used for data analysis.

Study Type

Interventional

Enrollment (Actual)

54

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Taiwan
    • Shih-Lin
      • Taipei, Shih-Lin, Taiwan, 111
        • Shinkong Wu-Ho-Su memorial hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

Yes

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • emergency medical technician-paramedics experienced in advanced airway management and CPR

Exclusion Criteria:

  • NA

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Crossover Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: clean airway
CPR and endotracheal intubation in an airway without regurgitation
Experimental: regurgitation airway
CPR and endotracheal intubation in an airway with regurgitation
Device: SALAD simulation device
An airway CPR manikin was modified to simulate regurgitation during CPR . A manual pump was fixed on the bottom of the torso to simulate the stomach. A clear vinyl tube was connected the manikin's oesophagus and the outflow port of the pump. A water container outside the manikin was filled with simulated gastric content and connected to the inflow port of the pump through another vinyl tube. The manikin's left main bronchus was occluded using a red cap provided by the manufacturer. The lung was simulated by an anaesthesia breathing bag placed outside the manikin and connected to the manikin's right main bronchus via a breathing circuit. A compression pad was attached to the bottom of the manikin's compression plate. During chest compression, the compression pad squeezed the pump to regurgitate gastric contents into the oropharynx

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
chest compression fraction
Time Frame: 3 hours
the proportion of time spent performing chest compressions during arrest
3 hours

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
intubation success rate
Time Frame: 3 hours
the rate of successful intubation
3 hours

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Shin Kong Wu Ho-Su Memorial Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

July 1, 2018

Primary Completion (Actual)

March 11, 2019

Study Completion (Actual)

March 11, 2019

Study Registration Dates

First Submitted

February 17, 2022

First Submitted That Met QC Criteria

March 9, 2022

First Posted (Actual)

March 14, 2022

Study Record Updates

Last Update Posted (Actual)

May 5, 2022

Last Update Submitted That Met QC Criteria

April 28, 2022

Last Verified

February 1, 2022

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 20180503R

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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