Compromised Cardiopulmonary Resuscitation Quality Due to Regurgitation During Endotracheal Intubation: a Randomised Crossover Manikin Simulation Study

Overview

Journal BMC Emerg Med

Publisher Biomed Central

Specialty Emergency Medicine

Date 2022 Jul 9

PMID 35810275

Authors

Li-Wei Lin

James Ducanto

Chen-Yang Hsu

Yung-Cheng Su

Chi-Chieh Huang

Shih-Wen Hung

Affiliations

Soon will be listed here.

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.

References

Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J . Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009; 120(13):1241-7. PMC: 2795631. DOI: 10.1161/CIRCULATIONAHA.109.852202. View

Root C, Mitchell O, Brown R, Evers C, Boyle J, Griffin C . Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management. Resusc Plus. 2021; 1-2:100005. PMC: 8244406. DOI: 10.1016/j.resplu.2020.100005. View

Benger J, Kirby K, Black S, Brett S, Clout M, Lazaroo M . 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. PMC: 6142999. DOI: 10.1001/jama.2018.11597. View

Vadeboncoeur T, Stolz U, Panchal A, Silver A, Venuti M, Tobin J . Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation. 2013; 85(2):182-8. DOI: 10.1016/j.resuscitation.2013.10.002. View

Kleinman M, Brennan E, Goldberger Z, Swor R, Terry M, Bobrow B . 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):S414-35. DOI: 10.1161/CIR.0000000000000259. View

Ruetzler K, Gruber C, Nabecker S, Wohlfarth P, Priemayr A, Frass M . Hands-off time during insertion of six airway devices during cardiopulmonary resuscitation: a randomised manikin trial. Resuscitation. 2011; 82(8):1060-3. DOI: 10.1016/j.resuscitation.2011.03.027. View

Piegeler T, Roessler B, Goliasch G, Fischer H, Schlaepfer M, Lang S . Evaluation of six different airway devices regarding regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) - A human cadaver pilot study. Resuscitation. 2016; 102:70-4. DOI: 10.1016/j.resuscitation.2016.02.017. View

Prekker M, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea T . The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014; 42(6):1372-8. PMC: 4902016. DOI: 10.1097/CCM.0000000000000213. View

Lin L, Huang C, Ong J, Chong C, Wu N, Hung S . 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. PMC: 6867733. DOI: 10.1097/MD.0000000000017898. View

10.

Wang H, Schmicker R, Daya M, Stephens S, Idris A, Carlson J . 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. PMC: 6583103. DOI: 10.1001/jama.2018.7044. View

11.

Ducanto J, Serrano K, Thompson R . Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System. West J Emerg Med. 2017; 18(1):117-120. PMC: 5226742. DOI: 10.5811/westjem.2016.9.30891. View

12.

Nolan J, Maconochie I, Soar J, Olasveengen T, Greif R, Wyckoff M . Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020; 142(16_suppl_1):S2-S27. DOI: 10.1161/CIR.0000000000000890. View

13.

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):879-84. DOI: 10.1016/j.resuscitation.2014.02.026. View

14.

Simons R, Rea T, Becker L, Eisenberg M . The incidence and significance of emesis associated with out-of-hospital cardiac arrest. Resuscitation. 2007; 74(3):427-31. DOI: 10.1016/j.resuscitation.2007.01.038. View

15.

Voss S, Rhys M, Coates D, Greenwood R, Nolan J, Thomas M . How do paramedics manage the airway during out of hospital cardiac arrest?. Resuscitation. 2014; 85(12):1662-6. PMC: 4265730. DOI: 10.1016/j.resuscitation.2014.09.008. View

16.

Wang H, Simeone S, Weaver M, Callaway C . Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009; 54(5):645-652.e1. DOI: 10.1016/j.annemergmed.2009.05.024. View

17.

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):168-9. DOI: 10.1016/j.jclinane.2014.07.004. View

18.

Michalek P, Donaldson W, Vobrubova E, Hakl M . Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine. Biomed Res Int. 2016; 2015:746560. PMC: 4691459. DOI: 10.1155/2015/746560. View

19.

Vaillancourt C, Petersen A, Meier E, Christenson J, Menegazzi J, Aufderheide T . 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. PMC: 7483839. DOI: 10.1016/j.resuscitation.2020.06.016. View

20.

Virkkunen I, Ryynanen S, Kujala S, VUORI A, Piilonen A, Kaaria J . Incidence of regurgitation and pulmonary aspiration of gastric contents in survivors from out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2007; 51(2):202-5. DOI: 10.1111/j.1399-6576.2006.01229.x. View