심정지관련 Journal Review 2017 American Heart Association and European Resuscitation Council Guideline Update 오제혁 중앙의대중앙대학교병원응급의학과대한심폐소생협회 BLS 위원회학술분과, 기획위원회, 대외협력위원회위원 들어가며 International Liaison Committee on Resuscitation (ILCOR) 는 2000년 Guidelines 2000 for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) 를개발하여발표하였고, 이후 5년주기로근거들을평가하여 International consensus on CPR and ECC science with treatment recommendations (CoSTR) 을출판해왔습니다. 1-4) ILCOR의주요한소속단체인 American Heart Association (AHA) 와 European Resuscitation Council (ERC) 는 ILCOR CoSTR의권고안을반영하여지침을개정해왔고, 가장최근에발표된지침은 2015년에출판되었습니다. 5,6) 대한심폐소생협회에서도 2015 ILCOR CoSTR을수용개작하여 2015년한국심폐소생술지침을발표한바있습니다. 7) ILCOR에서 5년주기로근거를평가하여 CoSTR을발표했던이유는새로운근거들을체계적으로검토하여새로운지침과교육자료를만들수있었기때문이나, 새롭게발표되는근거들을신속하게현장에적용하려면근거검토주기를단축해야된다는의견이대두되었습니다. 따라서, ILCOR에서는 2016년부터상시근거를검토하여 연단위로 CoSTR 요약논문을출판하기로결정하였습니다. 그첫번째결과물인 2017 CoSTR이 2017년말에발표되었고, 이후 AHA와 ERC에서올해 1월과 2월각각의 2017년심폐소생술지침일부개정안을 Circulation 저널과 Resuscitation 저널에게재하였습니다. 8-12) 5년마다몰아서공부하던지침을매년새롭게익혀야한다니그리반가운소식은아니었지만, 심장정지환자의생존율향상을위해이정도는감수하기로하고개정된내용을살펴보았습니다. 다행스럽게도 2015년지침과비교하여큰폭의개정은없었고, 병원밖에서응급의료서비스제공자에의해서시행되는현장심폐소생술의지침에일부변경이있었습니다. 2017 ILCOR CoSTR 2017 CoSTR은심폐소생술지침의기본소생술영역중인공호흡없이시행되는가슴압박소생술 (Compression-only CPR) 과인공호흡을포함한고식적인심폐소생술 (Conventional CPR) 을비교한근거들을집중적으로평가하였습니다. 이는 2015 CoSTR에서다뤄졌지만일부해결되지못 12
했던연속된가슴압박전략과관련된대규모인간대상연구결과들이 2015 CoSTR 출판이후인 2015년 8월이후에발표되었기때문입니다. 13-16) 2020년까지기다리기에는너무오랜시간이라고느껴진것일까요? 다만, 2017 CoSTR의주요권고안을 AHA와 ERC가다른방식으로받아들인점이주목됩니다. 이내용은글의말미에말씀드리기로하고 2017년지침의개정내용을 AHA, ERC 순서로살펴보겠습니다. 2017 AHA 소아기본소생술지침개정최근발표된소아환자대상연구에서는가슴압박소생술이고식적인심폐소생술보다좋은결과를보이지못했습니다. 15,16) 따라서, 심장정지영아와소아에서는인공호흡을포함한고식적인심폐소생술을시행하도록권장한 2015년지침을다시강조하였고 (Class I; level of evidence B-Nonrandomized), 만약목격자가인공호흡을할수없는경우에는가슴압박소생술을시행하도록권고하였습니다 (Class I; level of evidence B-Nonrandomized). 따라서, 2015년지침과달라진것이없습니다. 2017 AHA 성인기본소생술지침개정심장정지성인환자의경우 AHA는가슴압박소생술의보급이생존율을큰폭으로향상시켰다고 Circulation 저널에보고한 Iwami 등 14) 의연구결과를반영하여병원밖성인심장정지에서훈련을받지않은일반인구조자는전화교환상담원의도움여부와상관없이가슴압박소생술을시행하며 (Class I; level of evidence C-limited data), 가슴압박소생술교육을받은일반인구조자는가슴압박소생술을제공할것을권고 (Class I; level of evidence C-limited data) 하도록지침을강화하였습니다. AHA 2015년지침의경우일반인구조자는고식적인심폐소생술의합리적인대안으로가슴압박소생술을고려할수있는것 (Class IIa; level of evidence C-limited data) 으로권고하는수준이낮았었습니다. 고식적인심폐소생술교육을받은일반인구조자는고식적인심폐소생술을시행할수있는것 (Class IIa; level of evidence C-limited data) 은 2015년지침과차이가없습니다. 응급의료서비스제공자가병원밖에서심폐소생술을제공할때전문기도기가삽입되기전까지는가슴압박과인공호흡을 30:2의비율로시행하는것은 2015년지침과차이가없습니다. 그러나, 전문기도기가삽입되기전에도가슴압박을멈추지않고지속하면서 6초에 1회즉, 분당 10회의속도로동시에환기를제공하는방법을추가하였습니다 (Class IIb; level of evidence B-randomized). 이권고에대한근거는 2015년 12월 Nichol 등 13) 이 New England Journal of Medicine 저널에출판했던 Trial of continuous or interrupted chest compressions during CPR 연구입니다. 이연구는병원밖성인심장정지환자에게일정기간동안 (6분) 가슴압박과인공호흡을 30:2의비율로시행하는환자군과전문기도기를삽입하지않은상태에서분당 10회의속도로양압환기를제공하면서가슴압박을멈추지않고시행 (asynchronous ventilation during continuous chest compressions) 하는환자군의생존율을비교한무작위대조임상시험으로두군간에생존율의차이가없었습니다. 두군간에차이가없었기때문에굳이위와같은환기방식을지침에추가할필요가있었는지에대해서논란의여지가있습니다. 물론인간을대상으로한무작위대조임상시험의결과였기때문에근거의수준은높겠지만, 위연구의쟁점은가슴압박을지속한경우와그렇지않은경우를비교한것이므로연구프로토콜의중하나였던전문기도기를삽입하기전에양압환기를동시에시행하는기법을선택하는것이환자의생존율향상에도움이된다고판단하기는어렵기때문입니다. 결국 AHA는연속된가슴압박프로토콜을매우중요하게받아들이고있는 Korean Association of CardioPulmonary Resuscitation Newsletter 13
것으로보이나, 이에대한근거는동물실험의결과이므로인간대상연구결과만을채택하겠다는 AHA의근거채택원칙을스스로무시하고있는셈이라역설적일수밖에없습니다. 17) 여하튼 2017 CoSTR에서는위프로토콜을강한권고로추가하도록제시하고있고, AHA에서는이를받아들였습니다. 또한, AHA 2015년지침은의례적으로수동환기기법 (Passive ventilation technique: 심폐소생술중가슴압박의중단을최소화하기위해인공호흡없이기도유지기와산소마스크를통해고농도의산소를제공하는기법 ) 을권고하지는않았지만, 연속된가슴압박을포함한수동환기기법을응급의료서비스에서여러치료방법중하나로채택할수있다고제시하고있으며 (Class IIb, level of evidence C-limited data), 2017년지침에서도병원밖에서목격된제세동이가능한심전도리듬을가진성인심장정지환자의경우수동환기기법을유지하기로결정하였고, 전문기도기를삽입하기전양압환기를동시에시행하는환기방법이이를대체하는것은아니라고추가로언급하고있습니다. 그이외전문기도기삽입후가슴압박은멈추지않고지속하면서환기는 6초에 1회씩제공하는것 (Class IIb, level of evidence C-limited data) 과성인심장정지환자에게심폐소생술을시행할때가슴압박과인공호흡을 30:2의비율로제공하는것 (Class IIa, level of evidence C-limited data) 은 2015년지침과차이가없습니다. 2017 ERC 소생술지침개정 ERC 지침에는큰변화가없습니다. 또한, Nichol 등 13) 의연구결과에대해서도 AHA와달리해석하여 2017 CoSTR를수용하지않았습니다. 즉, 전문기도기를삽입하기전분당 10회의속도로양압환기를제공하면서가슴압박을멈추지않고시행하는군의추가적인이득이없는것으로결론을내리고전문기도기를삽입하기전 에는가슴압박과인공호흡을 30:2의비율로시행하는기존지침을고수하였습니다. 또한, 부연설명을통해 ERC는 AHA에서권고하는연속된가슴압박을포함한수동환기기법을권고하지않는다고 2017년개정안에명시하고있습니다. ERC의소아기본소생술지침역시 2015년지침과차이가없으며, 소아소생술을시행할수없는구조자의경우가슴압박소생술을선택할수있겠지만, 소아심장정지의원인이질식인점을고려할때구조호흡을소생술단계에추가하는것이바람직할것이라고제언하고있습니다. 맺음말 2017 CoSTR와 2017 AHA 지침개정안은가슴압박소생술, 즉, 연속된가슴압박전략을심장정지환자의나이 ( 예, 영아, 소아, 성인등 ), 심장정지가발생한장소 ( 예, 병원밖또는병원안등 ) 나심폐소생술을시행하는구조자 ( 예, 일반인, 119대원과같은보건의료서비스제공자, 의료인등 ) 와관계없이확대시킬수있는지에대해서집중적으로검토한것으로판단되며, 그결과일부지침에변경이있었습니다. 그러나, 연속된가슴압박전략을모든경우로확대시키기에는아직근거가부족하며, 같은연구결과를놓고도 ILCOR, AHA와 ERC가해석하고받아들이는데차이가있다는점이흥미롭게여겨집니다. 차후진행될한국심폐소생술지침개정작업에서도이와같은다양한관점에대해충분한고민이필요하겠습니다. 또한, 연속된가슴압박프로토콜을선호하는 AHA와 ILCOR의기조를고려할때해당프로토콜을검증하려는연구가늘어나고, 실제로주요저널에서관심있게다뤄질것으로예상되므로한국의소생의학연구자들도이점에주목해야될것입니다. 14
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