Dallas 2015 TFQO: David Stanton COI 328 EVREVs: Volker Wenzel COI 253& Emmanuelle Bourdon COI 333 Taskforce: BLS Passive ventilation techniques.

Dallas 2015

TFQO: David Stanton COI 328EVREVs: Volker Wenzel COI 253& Emmanuelle Bourdon COI 333Taskforce: BLS

Passive ventilation techniques

Dallas 2015COI Disclosure (specific to this systematic review)

Commercial/industryNone

Potential intellectual conflictsNone

Dallas 20152010 Treatment Recommendation

For lay rescuers performing chest compression–only CPR, there is insufficient evidence to recommend the use of any specific passive airway manoeuvre or adjunct ventilation device.

Dallas 2015C2015 PICO

Population:Among adults and children who are in cardiac arrest in any setting Intervention:does addition of any passive ventilation technique (eg positioning the body, opening the airway, passive oxygen administration) to chest compression-only CPR Comparison:compared with just chest compression-only CPR Outcomes:change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, bystander initiated CPR, oxygenation

Dallas 2015Inclusion/Exclusion& Articles Found

InclusionPublished comparative studies

ExclusionAnimal and manikin studiesUnpublished data, letters

23 Articles reviewed, and 3 included for review

Dallas 20152015 Proposed Treatment Recommendations

We suggest that in cardiac arrest in the prehospital setting, EMS providers may consider passive ventilation using an orophyrangeal tube and oxygen delivery mask while performing continuous chest compressions (weak evidence, low quality of evidence, subject to serious bias).

Dallas 2015 Risk of Bias in studies

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Dallas 2015Evidence profile table

Dallas 2015

Evidence profile table

Dallas 2015

Evidence profile table

Dallas 2015Proposed Consensus on Science statements

For the critical outcome of „favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year,“, we identified two studies; one randomized controlled trial (Saissy JM 2000;1523) and one retrospective study (Bobrow BJ 2009;656). Both studies were downgraded due to risk of serious bias. Saissy et al studied continuous insufflation of air or oxygen (CIO) through microcannulas inserted into the inner wall of a modified intubation tube and generating a permanent positive intrathoracic pressure; endpoints were respiratory effects of the intervention compared with intermittent positive pressure ventilation; however, none of the patients in either group survived to hospital discharge. In the Bobrow et al. study, paramedics selected either oropharyngeal airway and high flow oxygen by nonrebreather facemask [46/459 (10%) survivors with adjusted neurologically intact survival to hospital discharge)] without assisted ventilation, or bag-valve-mask ventilation at 8/min [53/560 (9.5%)] survivors with adjusted neurologically intact survival to hospital discharge]. There was an advantage with selected either oropharyngeal airway and high flow oxygen by nonrebreather facemask over bag-valve-mask ventilation in neurologically intact survival at hospital discharge in patients with witnessed VF/VT [39/102 (38.2%) vs. 31/120 (25.8%); OR 2.5 (95% CI 1.3-4.6)]; this positive effect vanished when assessing non-witnessed VF/VT [3/41 (7.3%) vs. 8/58 (13.8%); OR 0.5 (95% CI 0.2-1.6)], or non-shockable rhythms [4/316 (1.3%) vs. 14/381 (3.7%); OR 0.3 (95% CI 0.1-1.0)]..

Dallas 2015

For the critical outcome of survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, there was only data from the retrospective Bobrow et al. study, with identical numbers to the aforementioned analysis of neurologically intact (oropharyngeal airway and high flow oxygen by nonrebreather facemask [46/459 (10%) survivors with adjusted neurologically intact survival to hospital discharge)] without assisted ventilation vs. bag-valve-mask ventilation at 8/min [53/560 (9.5%)]. For the critical outcome of return of spontaneous circulation, there were two RCTs [the aforementioned Saissy study and Bertrand C 2006;843 (constant flow insufflation of oxygen (CFIO) through Boussignac multichannel endotracheal compared to standard endotracheal intubation and mechanical ventilation)] and the aforementioned study by Bobrow et al. In the Saissy study, outcome of experimental treatment vs. standard treatment was comparable [13/48 (27.1%) vs. 10/47 (21.3%) P=NS, calculated OR 0.71 (95 % CI 0.27 to 1.82)]; in the Bertrand study it was comparable as well [67/355 (19%) vs. 71/341 (21%) P=0.99, calculated OR 1.13 (95 % CI 0.7786 to 1.6411) and also comparable in the retrospective Bobrow et al study [123/459 (26.8%) vs. 169/560 (30.2%), reported OR 0.8 (0.7-1.0)]. For the important outcome of “oxygenation”, there were two RCTs [the aforementioned Saissy and Bertrand study, while the aforementioned study by Bobrow et al. did not report respiratory parameters. In the Saissy study, outcome of experimental treatment vs. standard treatment was PaO2 375 ± 147 vs. 195 ± 101 mm Hg (ICU admission) and PaCO2 34 ± 3 vs. 65 ± 18 mm Hg (ICU admission); both P<0.05. In the Bertrand study, outcome of experimental treatment vs. standard treatment was 35% vs. 25% with SpO2 >70% (P=0.009). However, quality was low in both studies. For the important outcome of “bystander CPR”, data was available in the Bertrand and Bobrow studies; outcome of experimental treatment vs. standard treatment in the Bertrand study was 31/355 (9%) vs. 33/341 (10%); P=0.65; while it was in the Bobrow study 177/459 (38.6%) vs. 242/560 (43.2%); P=n/a, reported OR 0.8 (0.6-1.1).

Dallas 2015Draft Treatment Recommendations

We suggest that in cardiac arrest in the prehospital setting, EMS providers may consider passive ventilation using an orophyrangeal tube and oxygen delivery mask while performing continuous chest compressions (weak evidence, low quality of evidence, subject to serious bias).

Dallas 2015Knowledge Gaps

This topic may relate to the EMS compression only worksheetTrue patency of airway never verified in studies selected, movement of air induced by chest compressions highly variable, changes over time, and never measuredSpecific research required

More studies required to improve qualityNo data in paeds