Intubation For Cardiac Arrest Research Articles

Evaluating the Efficacy of Pre-hospital Endotracheal Intubation in Cardiac Arrest: A Meta-Analysis.

The optimal airway management strategy during cardiac arrest remains a subject of ongoing debate. This study aims to con-tribute to the literature on pre-hospital endotracheal intubation (ETI) during cardiac arrest by assessing its association with improved patient outcomes, specifically a higher incidence of return of spontaneous circulation (ROSC). Additionally, the study seeks to determine if ETI remains the best practice for airway management. Methods: A comprehensive literature review was conducted using the Medline Complete and CINAHL Complete databases. The PICOT formula guided the selection of search terms, and a systematic search strategy was employed. Inclusion criteria focused on English-language, peer-reviewed, full-text articles published between 2010 and 2020, with a preference for stud-ies conducted in pre-hospital settings. The search identified 78 eligible articles, with six high-quality studies included in the final analysis. Results: The included articles, primarily from the United States, Europe, the United Kingdom, and Japan, involved a total of 341,286 participants. Meta-analysis results indicated no significant difference between ETI and control groups for 96.63% of pre-hospital cardiac arrests. The study participants received either ETI or basic airway management techniques, such as bag valve masks and supraglottic airway devices. The data suggests that ETI does not provide a substantial advantage over basic airway management techniques in terms of improving patient outcomes. Conclusion: This meta-analysis supports the growing body of evidence suggesting that pre-hospital endotracheal intubation is not significantly associated with better outcomes in cardiac arrest cases compared to basic airway management tech-niques. While ETI is not linked to poorer patient outcomes, the study recommends further investigation to definitively con-firm whether pre-hospital endotracheal intubation increases a patient's chances of survival after cardiac arrest.

Factors associated with short- and long-term outcomes in lung cancer patients requiring unplanned invasive mechanical ventilation

ObjectiveUnplanned invasive mechanical ventilation (IMV) is associated with high mortality in lung cancer patients. We aimed to identify factors associated with weaning from IMV, intensive care unit (ICU) survival and 1-year survival in lung cancer patients requiring unplanned IMV. DesignRetrospective observational study (2007–2017). SettingUniversity-affiliated ICU. PatientsLung cancer patients requiring unplanned IMV. InterventionNone. Main variables of interestWeaning from IMV, ICU and 1-year survival. ResultsOf the 136 patients included in the analysis (age 64 (9) years, male 110 (81%), metastatic disease 97 (62%)), 52 (38%) were weaned from IMV, 51 (38%) were discharged from ICU and 22 (16%) were alive at 1year. The main indication for intubation was acute respiratory failure. In multivariate analysis, PaO2/FiO2 >175mmHg at ICU admission and intubation before ICU admission were associated with successful weaning from IMV while intubation for cardiac arrest was associated with weaning failure. Same factors were associated with ICU survival. Absence of metastasis at ICU admission and lung resection surgery were independently associated with 1-year survival. ConclusionsA significant proportion of patients with lung cancer treated with unplanned IMV could be weaned from IMV and survived to ICU discharge, especially in the absence of severe hypoxemia at ICU admission. The low one-year survival was mostly driven by metastatic status.

Factors associated with short- and long-term outcomes in lung cancer patients requiring unplanned invasive mechanical ventilation

ObjectiveUnplanned invasive mechanical ventilation (IMV) is associated with high mortality in lung cancer patients. We aimed to identify factors associated with weaning from IMV, intensive care unit (ICU) survival and 1-year survival in lung cancer patients requiring unplanned IMV. DesignRetrospective observational study (2007–2017). SettingUniversity-affiliated ICU. PatientsLung cancer patients requiring unplanned IMV. InterventionNone. Main variables of interestWeaning from IMV, ICU and 1-year survival. ResultsOf the 136 patients included in the analysis (age 64 (9) years, male 110 (81%), metastatic disease 97 (62%)), 52 (38%) were weaned from IMV, 51 (38%) were discharged from ICU and 22 (16%) were alive at 1year. The main indication for intubation was acute respiratory failure. In multivariate analysis, PaO2/FiO2 >175mmHg at ICU admission and intubation before ICU admission were associated with successful weaning from IMV while intubation for cardiac arrest was associated with weaning failure. Same factors were associated with ICU survival. Absence of metastasis at ICU admission and lung resection surgery were independently associated with 1-year survival. ConclusionsA significant proportion of patients with lung cancer treated with unplanned IMV could be weaned from IMV and survived to ICU discharge, especially in the absence of severe hypoxemia at ICU admission. The low one-year survival was mostly driven by metastatic status.

Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial

Non-invasive ventilation has never been compared with high-flow oxygen to determine whether it reduces the risk of severe hypoxaemia during intubation. We aimed to determine if preoxygenation with non-invasive ventilation was more efficient than high-flow oxygen in reducing the risk of severe hypoxaemia during intubation. The FLORALI-2 multicentre, open-label trial was done in 28 intensive care units in France. Adult patients undergoing tracheal intubation for acute hypoxaemic respiratory failure (a partial pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FiO2] ratio of ≤300 mm Hg) were randomly assigned (1:1; block size, four participants) to non-invasive ventilation or high-flow oxygen during preoxygenation, with stratification by PaO2/FiO2 ratio (≤200 mm Hg vs >200 mm Hg). Key exclusion criteria were intubation for cardiac arrest, altered consciousness (defined as a Glasgow coma score of less than eight points), other contraindications to non-invasive ventilation (recent laryngeal, oesophageal, or gastric surgery, and substantial facial fractures), pulse oximetry not available, pregnant or breastfeeding women, and refusal to participate. The primary outcome was the occurrence of severe hypoxaemia (pulse oximetry <80%) during the procedure, assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02668458. Between April 15, 2016, and Jan 8, 2017, 2079 patients were intubated in the 28 participating units, and 322 were enrolled. We excluded five patients with no recorded data, two who withdrew consent or were under legal protection, one who was not intubated, and one who had a cardiac arrest. Of the 313 patients included in the intention-to-treat analysis, 142 were assigned to non-invasive ventilation and 171 to high-flow oxygen therapy. Severe hypoxaemia occurred in 33 (23%) of 142 patients after preoxygenation with non-invasive ventilation and 47 (27%) of 171 with high-flow oxygen (absolute difference -4·2%, 95% CI -13·7 to 5·5; p=0·39). In the 242 patients with moderate-to-severe hypoxaemia (PaO2/FiO2 ≤200 mm Hg), severe hypoxaemia occurred less frequently after preoxygenation with non-invasive ventilation than with high-flow oxygen (28 [24%] of 117 patients vs 44 [35%] of 125; adjusted odds ratio 0·56, 0·32 to 0·99, p=0·0459). Serious adverse events did not differ between treatment groups, with the most common immediate complications being systolic arterial hypotension (70 [49%] patients in the non-invasive ventilation group vs 86 [50%] patients in the high-flow oxygen group) and chest infiltrate on x-ray (28 [20%] vs 33 [19%]), and the most common late complications being death at day 28 (53 [37%] vs 58 [34%]) and ventilator-associated pneumonia during ICU stay (31 [22%] vs 35 [20%]). In patients with acute hypoxaemic respiratory failure, preoxygenation with non-invasive ventilation or high-flow oxygen therapy did not change the risk of severe hypoxaemia. Future research should explore the effect of preoxygenation method in patients with moderate-to-severe hypoxaemia at baseline. French Ministry of Health.

Defining the plateau point: When are further attempts futile in out-of-hospital advanced airway management?

BackgroundWe sought to characterize the number of attempts required to achieve advanced airway management (AAM) success. MethodsUsing 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility (“plateau point”). ResultsAmong 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9–71.9%), 4 attempts to reach 91.5% (91.2–91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1–67.0%), 3 attempts to reach 79.2% (78.4–80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3–63.9%), 3 attempts to reach 75.8% (73.7–77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1–77.1%), 5 attempts to reach 95.8% (95.3–96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1–68.6%), 3 attempts to 85.3% (83.9–86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0–89.3%), 5 attempts to reach 92.8% (92.3–93.4%) success plateau. ConclusionMultiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices.

Commentary to intubation strategy in cardiac arrest victims

Grier and Thomas seek to convince the reader that their preference for tracheal intubation in cardiac arrest is justified, whilst at the same time admitting that there is no evidence to support it. In addition, the proposal they make to provide a skilled practitioner working within a specialised team at every out of hospital cardiac arrest is impractical. The best approach to airway management during cardiac arrest is unknown, and the source of considerable controversy [1]. Views range from no airway management (compression-only CPR) to tracheal intubation, and in the absence of high quality randomised trials it is possible to find observational and anecdotal evidence that will support almost any belief. There are only two interventions that are proven to be effective in adult non-traumatic cardiac arrest (which makes up >90% of cardiac arrest cases): high quality continuous chest compressions and defibrillation where appropriate [2]. It is therefore essential that any airway management strategy does not interfere with these, yet tracheal intubation has been shown to be associated with long pauses in chest compressions [3], and where experienced practitioners attempt intubation but fail a return of spontaneous circulation (ROSC) is significantly delayed [4]. In the early stages of adult cardiac arrest not attributable to hypoxia there is a compelling argument for ignoring the airway entirely [5]. This, coupled with increased acceptability, is the main reason for advocating “compression only CPR” for bystanders who witness cardiac arrest, pending emergency medical services (EMS) arrival [6]. For EMS it may be reasonable to provide oxygenation through some form of assisted ventilation, however the best available evidence (meta-analysis of observational data) strongly supports basic airway management (bag-mask ventilation) alone [7]. This may be because it is the “safest” approach for EMS to take, and interrupts chest compressions least. One of the most intriguing possibilities is that the best results are achieved by those with minimal training, who are obliged to concentrate on chest compressions, defibrillation and bag mask ventilation because this is all that is available to

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Introduction: Rapid sequence intubation (RSI) is one of the most frequently performed procedures in emergency departments, but data describing the optimal sedative agent for induction during this procedure are limited. Hypothesis: The objective of this study was to compare the effectiveness of etomidate versus ketamine for RSI as measured by first-attempt intubation success. We hypothesized that ketamine is as effective as etomidate with regard to intubation success. Methods: This was a retrospective cohort study of prospectively collected data recorded in a quality improvement database between July 1st, 2007 and March 1st, 2012. The database contained information on all consecutive intubations performed in the emergency department during this time period. A multivariate logistic regression analysis was performed to determine the effect of sedative type on first-attempt intubation success. The model included other potential confounders such age, sex, trauma status, paralytic, difficult airway parameters, physician specialty, physician experience, reason for intubation and device used. Results: A total of 1511 RSIs were included in the final analyses. Of these, 1434 received etomidate and 77 received ketamine. The unadjusted rate of first-attempt intubation success was similar between the etomidate and ketamine groups (75% versus 83%, respectively; p=0.105;). In the multivariate analysis, variables predictive of first-attempt intubation success were sex (OR 0.70, 95% CI 0.99-1.00, p = 0.01), trauma status (OR 0.73, 95% CI 0.54-0.98, p = 0.04), intubation for cardiac arrest (OR 0.28, 95% CI 0.14-0.58, p<0.001), presence of at least one difficult airway parameter (OR 0.45, 95% CI 0.33-0.61, p<0.001), and use of GlideScope or C-Mac video laryngoscopes (OR 2.16, 95% CI 1.60-2.92, p < 0.001 and OR 2.23, 95% CI 1.51 to 3.28, respectively; p<0.001). After adjusting for potential confounders sedative type was not predictive of first-attempt intubation success (OR 0.72, 95% CI 0.38-1.36, p=0.305). Conclusions: Etomidate and ketamine produce equivalent rates of first-attempt intubation success in the emergency department.

Intubation in cardiac arrest: the ROC of our salvation?

Intubation in cardiac arrest: the ROC of our salvation?

Vocal cord paralysis following intubation.

<h3>To the Editor.—</h3> The report of Holley and Gildea on vocal cord paralysis following endotracheal intubation (<b>215</b>:281, 1971) in surgery leads us to report a case of unilateral vocal cord paralysis following intubation for cardiac arrest. <h3>Report of a Case.—</h3> A 19-year-old boy treated by hemodialysis for one year required revision of the arteriovenous shunt. On the second day of admission he suffered a hyperkalemic cardiac arrest with successful resuscitation. Endotracheal intubation was effected with a No. 34 cuffed rubber tube with the cuff expanded sufficiently to provide an air-tight seal. An MA-1 respirator provided oxygen. Eight hours later he was noted to have absent breath sounds in the left lateral part of the chest and the tube was withdrawn approximately 2 inches, with clinical improvement. The tube was removed after 76 hours, following which the patient complained of a sore throat and hoarseness. He was discharged ten days