INTUBATION IN ARREST – AGAIN

intubatedAnother study on airway management in cardiac arrest was just published in JAMA. The study was done in Denmark, where all intubations elective and emergency are done by anaesthestetists. It was a retrospective study, where they matched intubated patients with historical arrest patients not intubated at that same point in resus time. Intubation lowered the pt’s chance of survival to discharge with CPC 1-2. So, another study against intubation in cardiac arrest. Or?

The setting
This is hard, especially for us anaesthetists. We’re in the oxygen delivery business. Our job is to deliver oxygen through A, the Airways, into B Breathing, the lungs, and then into C, the circulation, to get that oxygen all the way out to the target organs and cells.

So, we need a functioning airway and lungs as well as a functioning circualtion. And an intubated, secure airway must be better than an unintubated one. Many studies have discussed how intubation take focus away from compressions and circulation, and therefore gives the patient more CPR downtime. Most intubations I see in Scandinavia are done either during continuous compressions, or with a very brief pause while passing the tube between the chords. I don’t think this is where the big problem is. The standard 30:2 circulation downtime during the breathing cycle for bag/mask ventilation is often longer than the brief pause for intubation.

Plastic allergy?
A tube down the trachea gives us a secured and always open airway, with good protection against aspiration. This tube is not the problem in itself. But it gives us the means to generate extremely high intrathoracic volumes and pressures, and to ventilate as often and as much as we want. This is what causes the problems we see with intubation in cardiac arrest. Not the intubation itself.

Positive pressure hyperventilation
I think the real problem is the following positive pressure ventilation. Through a cuffed tube, you can easily generate high intrathoracic pressures. These pressures will hinder venous return and preload. This will give worse cerebral flow and oxygenation as well as worse coronary flow and can reduce chances of ROSC as well as survival. And very often I see normo- to hyperventilation during CPR.

Oxygenation in arrest
We’re thinking about oxygenation in arrest patients all wrong. This is a patient in cardiac arrest, and even with optimal compressions, in an extreme low-flow state, so the amount of red cells passing through the lungs per minute is very low. So, you need very little extra oxygen to saturate those red cells. Oxygenation of the few hemoglobins passing through the lungs close to alveoli is not the problem, getting the oxygen out to the target organs is.

Still, we see low PaO2 levels during CPR, probably due to atlectasis and shunts in the pulmonary circulation. PEEP is the standard measure to keep the lungs open, but higher PEEP will definitely also hinder venous return and preload in arrest/low flow states.

The real conclusion
From the studies we have now, we can confidently say that intubation with or without CPR pauses still harms the patient with a standard ventilation strategy, which often is hyperventilation by hand. Ventilation should be low and slow.

Ventilation and compressions
And if you time ventilation with CPR, when’s the best time to squeeze the bag?
During relaxation, when it’s easier to get air into the lungs with low pressures, but also the cycle when blood is supposed to flow into the thorax, and the heart be perfused? During compressions, when inhalation will cause even higher intrathoracic pressures, but is also the time when compressions will hinder venous return anyway, and then let the relaxation phase be the venous return phase as per usual compression cycle? Or doesn’t compression cycle sync matter? The main point is probably just to ventilate infrequently.

Moving on
I’ve tried searching for animal experiments, as that’s probably the closest we’ll get to monitoring CPR physiology in a controlled fashion. There are a few studies out there, and we’ll discuss some of them in a future post. If anyone has good links to articles on ventilation and its impact on circualtion during CPR, please post in comments.

For now, let’s stop doing studies on intubation in cardiac arrest, and rather focus on studies optimising ventilation during cardiac arrest instead.

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival, JAMA 2017.

This entry was posted in Airway management, Anesthesia, CPR, Emergency Medicine, Prehospital Medicine. Bookmark the permalink.

8 Responses to INTUBATION IN ARREST – AGAIN

  1. Rory Naughton says:

    Is “low and slow” really the best?
    In the Fontan circulation reversal of pulmonary blood flow is seen throughout the inspiratory phase with IPPV. The optimum strategy is to limit the duration of this reversed flow (short Ti) rather than to limit the peak pressure as this is almost invariably greater than the venous filling pressure.
    Any thoughts?

  2. Wim Breeman says:

    Maybe worth tryingnout: Ventilation using a pressure relieve valve, so that (too) high intra thoracal pressures can not occure?

  3. Nico hoogerwerf says:

    Since we do 30:2 ventilation during mask ventilation, we can continue this in the intubated patients. At least it is more efficient than BMV.
    And don’t forget then the gastric tube since all (!) BMV patients have a lot of air in their stomach.

  4. J. Gollwitzer says:

    Not the ETT ist the problem. Intubation during ongoing compression, do 30:2 even after ETT (https://www.ncbi.nlm.nih.gov/m/pubmed/28349529/?i=4&from=continuous+chest+compressions), use max. 6ml/IBM. Maybe use ped bag.
    And…. cited study is about IHCOA; totally different patient population to OHCA. Also this study misses the most important point to make a statement – how long was the intubation time for patient and how long was CPR stopped for ETT!

  5. James DuCanto, M.D. says:

    It’s a short article, but it shows something very important–the manual air-mask-bag-unit (AMBU) is not the solution for ventilation during CPR.

    http://circ.ahajournals.org/content/114/Suppl_18/II_553.4.short

    It’s the bag. They would find the same results with Crics, if the patients were ventilated with AMBU.

    The Oxylator increases Cerebral Blood Flow and coronary perfusion pressure. Pick one up and learn to use it when you do deep sedations for cardioversions or eye blocks. Then use it to pre oxygenate prior to RSI in appropriate cases. Then realize it’s the perfect device to rescue patients during deep sedation (or when starting deep sedation, like for EGD endoscopies). Then use it as a transport ventilator when needed (when going from operating room to ICU).

  6. Thanos says:

    I am really concerned of the way the medical community interprets the results of new studies, subsequently contributing to the dissemination of data that irresponsibly question current knowledge and change daily clinical practice. In February 2017, a JAMA study (JAMA 2017;317:494-506) reported that patients who were intubated during in-hospital resuscitation were significantly less likely to survive to discharge, as well as to be discharged with good functional status than those who were not intubated. Within hours, an explosion of articles, views, and commentaries was noted in various Journals, Blogs, and social networking websites, all of these reporting that intubation during CPR should be abandoned. NO ONE and I mean NO ONE observed, among other, that the authors did not report the method of post-intubation ventilation (e.g. self-inflating bag or automated ventilator), which may be a significant limitation when assessing the success of CPR and survival rates (see link below). What is really objectionable though is the universal censorship that followed this publication, which almost forbidden the raising of any opposing opinion favoring intubation and mechanical ventilation during CPR. Unfortunately, this censorship characterized several resuscitation experts worldwide who were supporting the findings of the JAMA article, which is both sad and unacceptable.
    All of us must understand that there are no research authorities! If we want to increase survival after cardiac arrest we should always remember that we are responsible for every single word we say. Consequently, we must always be extremely careful, rational, accurate observers, and critical thinkers, in order to fulfill our role as scientists.

    https://www.ecronicon.com/ecan/pdf/ECAN-03-000037.pdf

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