Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A Nationwide, Population-based, Observational Study

Tanabe, Seizan; Ogawa, Toshio; Akahane, Manabu; Koike, Soichi; Horiguchi, Hiromasa; Yasunaga, Hideo; Mizoguchi, Tatsuhiro; Hatanaka, Tetsuo; Yokota, Hiroyuki; Imamura, Tomoaki

doi:10.1016/j.jemermed.2012.02.026

Cited by 62 publications

(63 citation statements)

References 24 publications

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“…Recent studies, however, have reported worse outcomes for out-of-hospital cardiac arrest patients managed with EADs compared to intubation, and it has been suggested that this may be attributable to neck vessel compression. 1,2,10 While the results of our small study cannot fully refute this claim, they do suggest that the compressive effect on cerebral arterial blood flow may not entirely account for the noted differences in outcome.…”

Section: Discussioncontrasting

confidence: 56%

Radiographic Evaluation of Carotid Artery Compression in Patients With Extraglottic Airway Devices in Place

White¹,

Braude²,

Lorenzo

et al. 2015

Academic Emergency Medicine

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Objectives: Extraglottic airway devices (EADs) are now commonly placed for airway management of critically ill or injured patients, particularly by emergency medical services providers in the out-ofhospital setting. Recent literature has suggested that EADs may cause decreased cerebral blood flow due to compression of the arteries of the neck by the devices' inflated cuffs. Methods:The authors identified a cohort of 17 patients presumed to be hemodynamically stable with EADs in place who underwent radiographic imaging of the neck. These studies were reviewed by a neuroradiologist to determine if mechanical compression of the carotid arteries was present.Results: None of the 17 cases reviewed had radiographically evident mechanical compression of the carotid artery. Conclusions:Until further studies are performed in which cerebral perfusion is evaluated prospectively in both hemodynamically stable and unstable human subjects, there is insufficicent evidence to recommend against the use of extraglottic airways in the emergency setting on the basis of carotid artery compression.ACADEMIC EMERGENCY MEDICINE 2015;22:636-638 © 2015 by the Society for Academic Emergency Medicine E xtraglottic airway devices (EADs) are commonly placed by emergency medical services (EMS) providers for airway management of critically ill or injured patients in the prehospital setting, and less commonly by physicians in the emergency department (ED). 1 Most EADs use an inflatable cuff in the hypopharynx to prevent airflow into the esophagus and to direct airflow into the trachea and lungs (see Figure 1). There exists a theoretical concern that the inflated cuffs on these devices may cause compression of the arteries in the neck that supply the brain. A recent study by Segal et al. 2 found a decrease in cerebral blood flow when EADs were used in a swine model. Colbert et al. 3 demonstrated that the laryngeal mask airway (LMA) cuff had an effect on the carotid bulb cross-sectional area and blood flow. Nandwani et al. 4 noted no sonographically evident displacement or compression of the internal jugular vein and the carotid artery in human subjects when an LMA was placed. In this study, we took advantage of a common practice at our institution in which well-functioning EADs placed in the field are left in situ for initial resuscitation and imaging in the ED. As a result, we have a number of patients who have undergone cross-sectional computed tomography (CT) studies of the cervical spine with various EADs in place. We examined whether or not mechanical carotid artery compression presumed to be secondary to the presence of the air-filled cuff in the hypopharynx was present in patients who underwent neck imaging studies and had EADs in place. We hypothesized that carotid artery compression would not be identified. METHODS Study DesignThis was a retrospective study of images acquired during usual care in our ED. This study received an exemption from our institutional review board.

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Section: Discussioncontrasting

confidence: 56%

Radiographic Evaluation of Carotid Artery Compression in Patients With Extraglottic Airway Devices in Place

White¹,

Braude²,

Lorenzo

et al. 2015

Academic Emergency Medicine

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“…33 For the critical outcome of 1-month survival, we have identified very-low-quality evidence (downgraded for very serious concerns about risk of bias, inconsistency, indirectness, and imprecision) from 1 observational study that showed no difference in 1-month survival between tracheal intubation and insertion of an EOA of an LMA (OR, 0.75; 95% CI, 0.3-1.9) 23 and very-low-quality evidence (downgraded for very serious risk of bias, inconsistency, indirectness, and imprecision) from another observation study that showed higher 1-month survival with tracheal intubation compared with insertion of an EOA of an LMA (OR, 1.03; 95% CI, 0.9-1.1).…”

Section: Sgas (Eoa and Lma) Versus Tracheal Intubationmentioning

confidence: 99%

Part 4: Advanced Life Support

Nolan¹,

Hazinski²,

Aickin³

et al. 2015

Circulation

554

125

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Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format) 3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs), 4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy, 5 and GRADE for observational studies that inform both therapy and prognosis questions. 6 GRADE evidence profile tables 7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low, 8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). 9 These evidence profile tables were then used to create a written summary of evidence for each outcome (the consensus on science statements). Whenever possible, consensus-based treatment recommendations were then created. These recommendations (designated as strong or weak) were accompanied by an overall assessment of the evidence and a statement from the task force about the values, preferences, and task force insights that underlie the recommendations. Further details of the methodology that underpinned the evidence evaluation process are found in "Part 2: Evidence Evaluation and Management of Conflicts of Interest."The task force preselected and ranked outcome measures that were used as consistently as possible for all PICO questions. Longer-term, patient-centered outcomes were considered more important than process variables and shorter-term outcomes. For most questions, we used the following hierarchy starting with the most important: long-term survival with neurologically favorable survival, long-term survival, short-term survival, and process variable. In general, longterm was defined as from hospital discharge to 180 days or longer, and short-term was defined as shorter than to hospital discharge. For certain questions (eg, related to defibrillation or confirmation of tracheal tube position), process variables such as termination of fibrillation and correct tube placement were important. A few questions (eg, organ donation) required unique outcomes....

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“…The 2015 systematic review identified large observational studies that challenged the routine use of advanced airways [59][60][61][62][63][64][65] and the use of epinephrine [66][67][68] as part of ALS. Because of the inherent risk of bias in observational studies, these data did not prompt a recommendation to change practice but do provide sufficient equipoise for large RCTs to test whether advanced airways and epinephrine are helpful during CPR.…”

Section: Hazinski Et Al Part 1: Executive Summary S5mentioning

confidence: 99%