Advanced Airway management during CPR is a Challenge

6th KACPR Symposium 2018, Sep 6 th The state of the art Resuscitation and beyond Consideration about Advanced Airway during CPR Resuscitation in the Hospital Hanyang University College of Medicine Dept. of Emergency Medicine Rapid Response Team Hyunggoo Kang, MD. PhD.

Advanced Airway management during CPR is a Challenge

Orders 1. Effect of advanced airway management in OHCA 2. Effect of advanced airway management in IHCA 3. Considered issues 1. Witnessed vs. Unwitnessed arrest 2. Prearrest diseases 3. Who perform? 4. Type of advanced airway

Advanced airway Early Advanced management in OHCA Late Advanced Airway Airway Hasegawa K, Hiraide A, Chang Y, et al. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of- Hospital Cardiac Arrest. JAMA, 2013; 309(3): 257 66. McMullan J, Gerecht R, Bonomo J, et al. Airway Management and Out-of-Hospital Cardiac Arrest Outcomes in the CARES Registry. Resuscitation, 2014 May; 85(5): 617 22. Wang HE, Szydlo D, Stouffer JA, et al. Endotracheal Intubation Versus Supraglottic Airway Insertion in Out-of-Hospital Cardiac Arrest. Resuscitation, 2012 Sep; 83(9): 1,061 6. Benoit JL, Gerecht RB, Steuerwald MT, McMullan JT. Endotracheal Intubation Versus Supraglottic Airway Placement in Out-of-Hospital Cardiac Arrest: A Meta-Analysis. Resuscitation, 2015 Aug; 93: 20 6. Shin SD, Ahn KO, Song KJ, Park CB, and Lee EJ. Out of hospital airway management and cardiac arrest outcomes: a propensity score matched analysis. Resuscitation. 2012;83: 313 319

American Journal of Emergency Medicine 34 (2016) 128 132

https://doi.org/10.1016/j.resuscitation.2018.04.024 https://doi.org/10.1016/j.resuscitation.2018.04.024

JAMA. 2017;317(5):494-506.

Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494-506.

J Nepal Health Res Counc 2017 Sep- Dec;15(37):286-9

Early advanced airway: bad effects Interruption of chest compression Hyperventilation and increased thoracic pressure Hyperoxia Possibility of intubation failure Difficulty of endotracheal intubation Bad effects of cerebral circulation Ballooning of SGA & ET tube

Delayed Advanced airway: Favors Shockable rhythm Witnessed arrest Cardiogenic causes Non-trauma No respiratory insufficiency

Considered issues 1. Witnessed vs. Unwitnessed arrest 2. Prearrest diseases 3. Who perform? 4. Type of advanced airways

Witnessed vs. Unwitnessed arrest Witnessed arrest Sudden collapse > hypoxia and hypercarbia > less importance of ventilator support Chest compression and early defibrillation Unwitnessed arrest Hypoxia and hypercarbia Severe respiratory and metabolic acidosis Need of early blood gas analysis Point of care test

Witnessed vs. Unwitnessed arrest High incidence of witnessed arrest (compared with OHCA) In medical facility ECG monitoring But Day(Office time) vs. Night Late night and early morning: increased unwitnessed arrest High incidence : at night time CPR at Night time Low quality CPR performance Lack of skillful providers

Prearrest diseases Causes of IHCA Cardiogenic causes < Other causes Initial rhythm: V-fib < PEA/asystole Underlying diseases and medications Effect of ventilation and oxygenation Pneumonia, sepsis, pulmonary edema Use of sedatives, pain killers, hypnotics Early ventilation and oxygenation is helpful Respiratory arrest Hypoxia

Who perform? Skillful airway managers Existence in wards and ICUs? RRT/anesthesia/emergency medicine CPR is a difficult situation for airway management in wards 기구및장비의부족 보조인력의숙련성 병동침대 : 머리쪽상판의미분리 이런상황이전문기도기삽입시혼란을야기해심폐소생술을방해

기관내삽관에익숙해지려면

Complications of Emergency Intubation - Mort TC. Anesth Analg 2004;99:607-13

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation? RESULTS: We analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI(<60s) required 137 experiences of ETIs (1,218 days of training). A 90% success rate for highly qualified ETI(<30s) required at least 243 experiences of ETIs (1,973 days of training). Resuscitation. 2018 Aug 30. doi: 10.1016/j.resuscitation.2018.08.032.

기관내삽관의어려움 원내심폐소생술시성문외기도기삽입으로의대체움직임 빠른반응을보일수있는의료진부족 의료진의기도관리능력미숙달 초기반응자들에의한 SGA 삽입으로기도확보 간호사또는저년차전공의시행 삽입교육및경험의부족 효과에대한근거부족

Alternative devices: Supraglottic Devices Wide use of 2 nd generation EGD i-gel LMA supreme Ambu Auragain

Alternative devices: Supraglottic Devices Wide use of 2 nd generation EGD i-gel LMA supreme Ambu Auragain

성문외기도기삽입영상 ( 성문쪽에서본영상 )

SGA(2 nd generation) 비교

SGA(2 nd generation) 비교

성문외기도기의약점 1. 밀착압력의부족 심폐소생술시에는후두의지속적흔들림이발생 밀착이되지않아효과적인환기의어려움발생 상부식도조임근에위치한기도기의 tip 이밀려나올가능성 i-gel > Auragain, LMA supreme 2. 잘못된삽입발생가능성 2 세대 SGA 는 tip 이두꺼워후두개를접을가능성증가 식도상부삽입의어려움 삽입의경험및연습이필요

Type of advanced airway Basic airway vs. advanced airway BMV is a difficult procedure In hospital, most healthcare providers are unskillful Endotracheal intubation vs. Supraglottic airway Direct laryngoscope vs. Videolaryngoscope

Direct VS. Video Laryngoscope Changes in the first-pass success rate with the GlideScope video laryngoscope and direct laryngoscope: a ten-year observational study in two academic emergency departments

Eye piece vs. video system

Endotracheal intubation during CPR

Canada 3 NICUs 34 residents 213 ETIs VL: 69%(1 st ), 91%(7 th ) CL: 33%(1 st ), 80%(7 th ) PEDIATRICS 2016: 37(3)

Resuscitation 89 (2015) 188 194

비디오후두경도훈련이필요하다

가슴압박을방해하는삽관 vs. 삽관을방해하는가슴압박 1. ACLS에서기관내삽관은필수적술기는아님 2. 하지만대부분병원에서는대부분시행 3. 가슴압박으로인한성문의움직임으로인한삽관의어려움 4. 가슴압박을방해하지않도록 5초이내의중지권장 5. 시야가넓은비디오후두경은방해없이시행용이

Summary 원내심폐소생술에서의효과적인기도 / 환기관리에대한연구근거부족 OHCA와다르게신속한 POC 검사 (blood gas analysis) 가가능하다면정보에근거해서결정필요 전문기도기를넣는결정을내린다면 직접후두경보다는비디오후두경을통한삽입이유리 성문외기도기사용을결정한다면적절한환기가이루어지는지반드시확인

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