Compromised cardiopulmonary resuscitation quality due to regurgitation during endotracheal intubation: a randomised crossover manikin simulation study

Li-Wei Lin, James DuCanto, Chen-Yang Hsu, Yung-Cheng Su, Chi-Chieh Huang, Shih-Wen Hung, Li-Wei Lin, James DuCanto, Chen-Yang Hsu, Yung-Cheng Su, Chi-Chieh Huang, Shih-Wen Hung

Abstract

Background: Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality.

Methods: An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time.

Results: During the first CPR-intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24-0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario.

Conclusion: Regurgitation during endotracheal intubation significantly reduces CPR quality.

Trial registration: ClinicalTrials.gov, NCT05278923 , March 14, 2022.

Keywords: Airway management; Cardiopulmonary resuscitation; Manikin; Regurgitation.

Conflict of interest statement

All authors declare no conflict of interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Manikin setup: A The outflow port of the pump (artificial stomach) was connected to the oesophagus, and the inflow port of the pump was connected to the water container via vinyl tubes. The right main bronchus was connected to an anaesthesia breathing bag through a breathing circuit, and the left main bronchus was occluded. The HQCPR device was attached to the inside of the compression plate. The compression pad was attached to the bottom of the compression plate for squeezing the pump during chest compression. B During the simulations, the HQCPR application on the Android tablet recorded the CPR quality metrics. The anaesthesia breathing bag was unclamped only for checking intubation. Abbreviations: CPR, cardiopulmonary resuscitation

References

    1. Jost D, Minh PD, Galinou N, Alhanati L, Dumas F, Lemoine F, Tourtier J-P. What is the incidence of regurgitation during an out-of-hospital cardiac arrest? Observational study Resuscitation. 2015;96:70.
    1. Simons RW, Rea TD, Becker LJ, Eisenberg MS. The incidence and significance of emesis associated with out-of-hospital cardiac arrest. Resuscitation. 2007;74(3):427–431. doi: 10.1016/j.resuscitation.2007.01.038.
    1. Virkkunen I, Kujala S, Ryynanen S, Vuori A, Pettila V, Yli-Hankala A, Silfvast T. Bystander mouth-to-mouth ventilation and regurgitation during cardiopulmonary resuscitation. J Intern Med. 2006;260(1):39–42. doi: 10.1111/j.1365-2796.2006.01664.x.
    1. Virkkunen I, Ryynanen S, Kujala S, Vuori A, Piilonen A, Kaaria JP, Kahara V, Pettila V, Yli-Hankala A, Silfvast T. Incidence of regurgitation and pulmonary aspiration of gastric contents in survivors from out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2007;51(2):202–205. doi: 10.1111/j.1399-6576.2006.01229.x.
    1. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42(6):1372–1378. doi: 10.1097/CCM.0000000000000213.
    1. Piegeler T, Roessler B, Goliasch G, Fischer H, Schlaepfer M, Lang S, Ruetzler K. Evaluation of six different airway devices regarding regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) - A human cadaver pilot study. Resuscitation. 2016;102:70–74. doi: 10.1016/j.resuscitation.2016.02.017.
    1. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009;54(5):645–652.e641. doi: 10.1016/j.annemergmed.2009.05.024.
    1. Kurz MC, Prince DK, Christenson J, Carlson J, Stub D, Cheskes S, Lin S, Aziz M, Austin M, Vaillancourt C, et al. Association of advanced airway device with chest compression fraction during out-of-hospital cardiopulmonary arrest. Resuscitation. 2016;98:35–40. doi: 10.1016/j.resuscitation.2015.10.011.
    1. Ruetzler K, Gruber C, Nabecker S, Wohlfarth P, Priemayr A, Frass M, Kimberger O, Sessler DI, Roessler B. Hands-off time during insertion of six airway devices during cardiopulmonary resuscitation: a randomised manikin trial. Resuscitation. 2011;82(8):1060–1063. doi: 10.1016/j.resuscitation.2011.03.027.
    1. Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, et al. 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. JAMA. 2018;320(8):769–778. doi: 10.1001/jama.2018.7044.
    1. Voss S, Rhys M, Coates D, Greenwood R, Nolan JP, Thomas M, Benger J. How do paramedics manage the airway during out of hospital cardiac arrest? Resuscitation. 2014;85(12):1662–1666. doi: 10.1016/j.resuscitation.2014.09.008.
    1. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, et al. Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circul. 2020;142(16_suppl_1):S2–S27. doi: 10.1161/CIR.0000000000000890.
    1. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417–435. doi: 10.1161/CIR.0b013e31829d8654.
    1. Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241–1247. doi: 10.1161/CIRCULATIONAHA.109.852202.
    1. Rea T, Olsufka M, Yin L, Maynard C, Cobb L. The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation. 2014;85(7):879–884. doi: 10.1016/j.resuscitation.2014.02.026.
    1. Vaillancourt C, Petersen A, Meier EN, Christenson J, Menegazzi JJ, Aufderheide TP, Nichol G, Berg R, Callaway CW, Idris AH, et al. The impact of increased chest compression fraction on survival for out-of-hospital cardiac arrest patients with a non-shockable initial rhythm. Resuscitation. 2020;154:93–100. doi: 10.1016/j.resuscitation.2020.06.016.
    1. Vadeboncoeur T, Stolz U, Panchal A, Silver A, Venuti M, Tobin J, Smith G, Nunez M, Karamooz M, Spaite D, et al. Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation. 2014;85(2):182–188. doi: 10.1016/j.resuscitation.2013.10.002.
    1. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S414–435.
    1. Michalek P, Donaldson W, Vobrubova E, Hakl M. Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine. Biomed Res Int. 2015;2015:746560. doi: 10.1155/2015/746560.
    1. Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779–791. doi: 10.1001/jama.2018.11597.
    1. Cook TM, Woodall N, Frerk C, Fourth National Audit P Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617–631. doi: 10.1093/bja/aer058.
    1. Fevang E, Haaland K, Roislien J, Bjorshol CA. Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial. BMC Anesthesiol. 2018;18(1):10. doi: 10.1186/s12871-018-0474-z.
    1. Sorour K, Donovan L. Intentional esophageal intubation to improve visualization during emergent endotracheal intubation in the context of massive vomiting: a case report. J Clin Anesth. 2015;27(2):168–169. doi: 10.1016/j.jclinane.2014.07.004.
    1. Kornhall DK, Almqvist S, Dolven T, Ytrebo LM. Intentional oesophageal intubation for managing regurgitation during endotracheal intubation. Anaesth Intensive Care. 2015;43(3):412–414. doi: 10.1177/0310057X1504300316.
    1. DuCanto J, Serrano KD, Thompson RJ. Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System. West J Emerg Med. 2017;18(1):117–120. doi: 10.5811/westjem.2016.9.30891.
    1. Root CW, Mitchell OJL, Brown R, Evers CB, Boyle J, Griffin C, West FM, Gomm E, Miles E, McGuire B, et al. Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management. Resuscitation Plus. 2020;1–2:100005. doi: 10.1016/j.resplu.2020.100005.
    1. Lin LW, Huang CC, Ong JR, Chong CF, Wu NY, Hung SW. The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation: A pilot before-after study. Medicine (Baltimore) 2019;98(46):e17898. doi: 10.1097/MD.0000000000017898.
    1. Pilbery R, Teare MD. Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study. Br Paramed J. 2019;4(1):14–21. doi: 10.29045/14784726.2019.06.4.1.14.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다