Elsevier

Resuscitation

Volume 139, June 2019, Pages 133-143
Resuscitation

Review
Advanced airway management during adult cardiac arrest: A systematic review

https://doi.org/10.1016/j.resuscitation.2019.04.003Get rights and content

Abstract

Aim

To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations.

Methods

The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies.

Results

We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses.

Conclusions

We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.

Introduction

Airway management during cardiac arrest is considered an integral part of cardiac arrest management with potential impact on patient outcome. The traditional approach has usually been initial bag-mask ventilation followed by advanced airway management with either a supraglottic airway or tracheal intubation1, 2 although there is limited supporting evidence for any of these approaches.3 Bag-mask ventilation has been considered to be a relatively simple technique and part of basic life support. However, bag-mask ventilation may be technically difficult with concerns that it might not provide adequate ventilation and oxygenation and there is a risk of aspiration using this approach. Tracheal intubation offers a secure airway and could therefore lower the risk of aspiration of gastric content. However, tracheal intubation might result in interruptions in chest compression and delays in other interventions. Furthermore, tracheal intubation is a skill that requires expertise and experience4 and esophageal intubation (or subsequent dislodgment of the tube) could result in unsuccessful resuscitation. Supraglottic airways are airway devices that are inserted blindly and placed in the hypopharynx to facilitate ventilation.2 These devices are relatively easy to insert and provide a middle-ground intervention between bag-mask ventilation and tracheal intubation. Given that all three approaches are currently being used in clinical practice and considering the theoretical pros and cons for each5, there has been a need for randomized trials to guide clinical practice.

During 2018 a number of randomized clinical trials6, 7, 8 were published addressing advanced airway management during adult cardiac arrest. These trials have included airway management strategies of bag-mask ventilation, supraglottic airway devices, and tracheal intubation. This systematic review will inform the International Liaison Committee on Resuscitation (ILCOR) consensus on science and treatment recommendations for advanced airway management during adult cardiac arrest.

Section snippets

Protocol and registration

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.9 The PRISMA checklist is provided in the Supplementary Contents. The protocol was prospectively submitted to the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018115556). The protocol is provided in the Supplementary Contents. The review was commissioned by ILCOR.

Eligibility criteria and outcomes

The study question was framed using the PICO (Population, Intervention, Comparison,

Study selection

The search identified 6400 unique titles/abstracts of which 6172 were excluded based on initial review (Kappa = 0.60). Of the 228 full-text articles reviewed, 141 were excluded for various reasons (Kappa = 0.91, Fig. 1). As two additional articles were identified through review of reference lists, a total of 89 articles were included. No studies assessing cost-effectiveness were identified.

Observational studies

Seventy-eight observational studies were included. Nine studies addressed timing of advanced airway

Discussion

In this systematic review on airway management in adult cardiac arrest, which was commissioned by ILCOR to inform an update of international guidelines, a large number of studies were identified. Despite the extensive literature on this topic, we only identified three large randomized clinical trials in OHCA6, 7, 8 and due to heterogeneity between these trials, we were unable to perform any meta-analyses.

More than 70 observational studies have been published on advanced airway management in

Limitations

The overall Kappa for the review of titles/abstracts was relatively low (Kappa = 0.60) which likely reflects difficulties in correctly identifying observational studies of airway management. However, based on subsequent review of reference lists and contact with content experts, we did not identify any additional articles that were missed during the review process and therefore do not believe this is a major limitation. Many of the decisions made in the process of this review are inherently

Conclusion

We identified a large number of studies related to advanced airway management in adult cardiac arrest. However, the majority were at a high risk of bias and heterogeneity across studies precluded any meaningful meta-analyses. Three recently published, large randomized trials on OHCA have improved the certainty of evidence and will help inform future guidelines. Trials addressing advanced airway management during IHCA are lacking.

Funding

This systematic review was funded by the American Heart Association, on behalf of the International Liaison Committee on Resuscitation (ILCOR). The following authors received payment from this funding source to complete this systematic review: Lars W. Andersen as Expert Systematic Reviewer. In addition, the St. Michael’s Hospital Health Sciences Library received payment from this funding source to enable David Lightfoot, information specialist to develop and apply the search strategy.

Conflicts of interest

Some of the authors (LWA, AG, MD, JS) and collaborators (JN) have published manuscripts related to advanced airway management. However, none of the authors have any financial conflicts of interests and none of the authors have academic conflicts related to ongoing or planned trials. Authors with identified conflicts of interest as per the guidance of the ILCOR Conflict of Interest Committee were not involved in the decision to include/exclude those articles and did not perform the initial data

Acknowledgements

The authors would like to thank David Lightfoot, information specialist at the St Michael’s Hospital Health Sciences Library, Li Ka Shing Knowledge Institute Toronto, ON, Canada, for preparing and conducting the systematic searches. The authors would also like to thank Ewa Gajda, Wolfgang A. Wetsch, Kamran Banan, Marcel Casasola, and Xiaowen Liu for assistance with translation of non-English articles.

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