Transcript ILCOR Slides ALS 714 SGA VS TT Dallas 2015

Dallas 2015
ALS 714 : Advanced airway
placement (SGA vs TT)
TFQO: Jerry Nolan #310
EVREV 1: Jerry Nolan COI #301
EVREV 2: Charles Deakin COI #221
Taskforce: ALS
COI Disclosure
Dallas 2015
(SPECIFIC to this systematic review)
Jerry Nolan COI #310
Commercial/industry
• Editor-in-Chief Resuscitation
Potential intellectual conflicts
• Co-applicant AIRWAYS-2 (igel versus intubation) NIHR Funded
Charles Deakin COI #221
Commercial/industry
• Editorial Board, Resuscitation
• Director, Prometheus Medical
Potential intellectual conflicts
• TMG, AIRWAYS-2 (igel versus intubation) NIHR Funded
2010 TR
Dallas 2015
Healthcare professionals trained to use
supraglottic airway devices may consider
their use for airway management during
cardiac arrest and as a backup or rescue
airway in a difficult or failed tracheal
intubation.
C2015 PICO
Dallas 2015
Population:
patients in cardiac arrest in any setting
Intervention:
Insertion of supraglottic airway as first advanced airway
Comparison:
Tracheal intubation as first advanced airway
Outcomes:
Survival with Favorable neurological/functional outcome
at discharge, 30 days, 60 days, 180 days AND/OR 1
year (9-Critical)
Survival only at discharge, 30 days, 60 days, 180 days
AND/OR 1 year (8-Critical)
Change ROSC, CPR parameters, aspiration pneumonia
Inclusion/Exclusion
& Articles Found
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The search yielded a total of 369 studies. Of
these, 2 RCTs and 15 observational studies were
included for bias assessment.
4 studies excluded after bias assessment because
they reported only blood gas data
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Risk of Bias in RCTs
Study
Year
Design
Total
Patients
Population
Industry
Funding
Allocation: Generation
Allocation: Concealment
Blinding: Participants
Blinding: Assessors
Outcome: Complete
Outcome: Selective
Other Bias
RCT bias assessment
Goldenberg
Rabitsch
1986
2003
RCT
RCT
175
172
OHCA
OHCA
No
Yes
Low
Low
Low
High
High
High
High
High
Low
High
High
Low
High
High
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Risk of Bias in non-RCTs
Study
Year
Design
Total
Patients
Population
Industry
Funding
Eligibility Criteria
Exposure/Outcome
Confounding
Follow up
Non-RCT bias asssesment
Bartlett
1992
2009
2011
1985
1985
2010
2011
2013
2014
2013
1993
2010
2013
2012
2010
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
Non-RCT
111
5822
351
169
48
1,294
5,377
281,522
8701
641
37
883
138,248
10,455
636
OHCA
OHCA
OHCA
OHCA
OHCA
OHCA
OHCA
OHCA
OHCA
OHCA
IHCA
OHCA
OHCA
OHCA
OHCA
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Unclear
High
High
High
Low
Low
Low
Low
Low
Unclear
Low
High
Low
Low
High
Unclear
High
Low
High
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
High
High
High
High
High
High
High
High
High
High
High
High
High
High
High
Unclear
Low
Low
High
Low
High
Low
Low
Low
Low
Low
Low
Low
Low
Low
Cady
Gahan
Geehr
Hammargren
Hanif
Kajino
Hasegawa
McMullan
Shin
Staudinger
Takei
Tanabe
Wang
Yanagawa
Dallas 2015
Proposed
Consensus on Science statements
EGTA (I) versus tracheal intubation (C)
For the critical outcome of survival to hospital discharge we have identified very
low quality evidence (downgraded for very serious concerns about risk of bias and
imprecision) from one RCT enrolling 175 OHCAs show no difference between
EGTA and tracheal intubation (OR 1.19 95% CI 0.5 - 3.0) [Goldenberg 1986 90]
Combitube (I) versus tracheal intubation (C)
For the critical outcome of survival to hospital discharge we have identified very
low quality evidence (downgraded for very serious concerns about risk of bias and
imprecision) from one RCT enrolling 173 OHCAs that showed no difference
between Combitube and tracheal intubation (OR 2.38 95% CI 0.5 – 12.1)
[Rabitsch 2003 27] and very low quality evidence from one observational study of
5822 OHCAs that showed no difference between tracheal intubation by
paramedics and Combitube insertion by emergency medical technicians (EMTs)
(adjusted OR 1.02; 95% CI 0.79 -1.30) [Cady 2009 495].
For the important outcome of ROSC we have identified very low quality evidence
from one observational study of 5822 OHCAs that showed no difference between
tracheal intubation by paramedics and Combitube insertion by emergency medical
technicians (EMTs) (adjusted OR 0.93; 95% CI 0.82 -1.05). [Cady 2009 495].
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Proposed
Consensus on Science statements
LMA (I) versus tracheal intubation (C)
For the critical outcome of survival to hospital discharge we have identified very
low quality evidence from one observational study of 641 OHCAs that showed
lower rates of survival to hospital discharge with insertion of an LMA compared
with tracheal tube (OR 0.69; 95% CI 0.4 – 1.3) [Shin 2012 313]
Supraglottic airways (SGAs: Combitube, LMA, laryngeal tube) versus
tracheal intubation
For the critical outcome of favourable neurological survival we have identified low
quality evidence from one observational study of 5377 OHCAs showing no
difference between tracheal intubation and insertion of a SGA (adjusted OR 0.71;
95% CI 0.39 – 1.30) [Kajino 2011 R236], from one observational study of
281,522 OHCAs showing higher rates of favourable neurological outcome
between insertion of a SGA and tracheal intubation (OR 1.11; 95% CI 1.0 – 1.2)
[Hasegawa 2013 257] and from two studies showing higher rates of favourable
neurological outcome between tracheal intubation and insertion of a SGA (8701
OHCAs adjusted OR 1.44; 95% CI 1.10 – 1.88 [McMullan 2014 617]) and
(10,455 OHCAs adjusted OR 1.40; 95% CI 1.04 – 1.89 [Wang 2012 1061]).
Dallas 2015
Proposed
Consensus on Science statements
Supraglottic airways (SGAs: Combitube and LMA) versus
tracheal intubation
For the important outcome of ROSC we have identified very low
quality evidence from one observational study of 713 OHCAs
that showed no difference between tracheal intubation and
Combitube or LMA insertion by EMTs or emergency life-saving
technicians (ELTs) (OR 0.65; 95% CI 0.4 – 1.2). [Yanagawa
2010 340].
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Proposed
Consensus on Science statements
•
•
•
•
Supraglottic airways (SGAs: Esophageal obturator airway and LMA) versus
tracheal intubation
For the critical outcome of neurologically favourable one-month survival we have
identified very low quality evidence from one observational study of 138,248 OHCAs that
showed higher rates of neurologically favourable one-month survival with tracheal
intubation compared with insertion of an esophageal obturator airway or LMA (OR 0.89;
95% CI 0.8 – 1.0). [Tanabe 2013 389]
For the critical outcome of one-year survival we have identified very low quality evidence
from one observational study of 923 OHCAs that showed no difference in one-year survival
with tracheal intubation compared with insertion of an esophageal obturator airway or LMA
(OR 0.89; 95% CI 0.3 – 2.6). [Takei 2010 715].
For the critical outcome of one-month survival we have identified very low quality
evidence from one observation study that showed no difference in one-month survival
between tracheal intubation and insertion of an esophageal obturator airway of an LMA (OR
0.75; 95% CI 0.3 – 1.9) [Takei 2010 715] and very low quality evidence from another
observation study that showed higher one-month survival with tracheal intubation
compared with insertion of an esophageal obturator airway of an LMA (OR 1.03; 95% CI
0.9 – 1.1) [Tanabe 2013 389]
For the important outcome of ROSC we have identified very low quality evidence from one
observational study of 923 OHCAs that showed a higher rate of ROSC with tracheal
intubation compared with insertion of an esophageal obturator airway or LMA (OR 0.71;
95% CI 0.4 – 1.2). [Takei 2010 715].
Dallas 2015
Draft
Treatment Recommendations
We suggest using either a supraglottic airway or
tracheal tube as the initial advanced airway
management during CPR (weak recommendation,
very low quality evidence) for out of hospital
cardiac arrest.
We suggest using either a supraglottic airway or
tracheal tube as the initial advanced airway
management during CPR (weak recommendation,
very low quality evidence) for in hospital cardiac
arrest.
Dallas 2015
Values and preferences
The type of airway used may depend on the skills
and training of the healthcare provider. Tracheal
intubation requires considerably more training and
practice.
Tracheal intubation may result in unrecognised
oesophageal intubation and increased hands off time
in comparison with insertion of a supraglottic airway.
Both a supraglottic airway and tracheal tube are
frequently used in the same patients as part of a
stepwise approach to airway management but this
has not been formally assessed.
Next Steps
Dallas 2015
This slide will be completed during Task
Force Discussion (not EvRev) and should
include:
Consideration of interim statement
Person responsible
Due date