Tyler F. Vadeboncoeur, MD

1

The Survival Rate from Witnessed Ventricular
Fibrillation Out-of-Hospital Cardiac Arrest is
Superior with Passive Oxygen Insufflation
Compared to Active Bag-Valve-Mask Ventilation

• Tyler F. Vadeboncoeur, MD
• College of Medicine, Mayo Clinic
• Mayo Clinic Jacksonville, FL
• Save Hearts in Arizona Registry and Education
• SHARE

2
Disclosures

• No industry device or pharmaceutical
  relationships

3
SHARE Team

• Bentley J. Bobrow, MD
• Lani Clark
• Vatsal Chikani, MPH
• Arthur B. Sanders, MD
• Karl B. Kern, MD
• Robert A. Berg, MD
• Gordon A. Ewy, MD

4
Cardiocerebral Resuscitation
Single shock if indicated without pulse check
or rhythm analysis
Single shock if indicated without pulse check
or rhythm analysis
Single shock without pulse check or rhythm
analysis
EMS arrival
200 chest compressions
200 chest compressions
200 chest compressions
200 chest compressions
CCC Only
Analysis
Analysis
Analysis
BVM or Passive Insufflation 15L NRB Begin IV
Resume Standard ACLS Consider Endotracheal
Intubation
Administer 1 mg IV Epinephrine

• If adequate bystander chest compressions are
  provided, EMS providers perform immediate rhythm
  analysis

5
Ventilation Rate During Out-of-Hospital CPR

• 13 out-of-hospital cardiac arrest patients
• Ventilation rate measured during CPR
• Average ventilation rate 303 per minute (range
  15-49)

Aufderheide et al. Circulation 2004 1091960-5
6
Adverse Effects of Positive Pressure Ventilation

• During CPR for cardiac arrest, positive pressure
  ventilation increases intra-thoracic pressure,
  decreases venous return to the chest and
  decreases blood flow to the heart and to the brain

Aufderheide T, Sigurdsson G, Pirrallo R,
Yannopoulos D, McKnite S, Briesen Cv, Sparks C,
Conrad C, Provo T, Lurie K. Hyperventilation-indu
ced hypotension during cardiopulmonary
resuscitation. Circulation. 20041091960-1965.
7
Passive Oxygen Insufflation Clinical Experience
50 40 30 20 10 0
48
p 0.001
Neurologically normal survival ()
15
CPR
CCR
Kellum, Kennedy, Ewy. Amer J Med 2006119335
8
Initiation of Cardiocerebral Resuscitation in
Arizona

• Although Cardiocerebral Resuscitation (which
  includes passive oxygen insufflation) was
  instituted by Kellum et al. in Rock and Walworth
  Counties, Wisconsin, there was concern that if
  paramedic/firefighters in the Arizona SHARE
  program were told that they could not perform
  endotracheal intubation nor use bag-valve-mask
  ventilation, that they would not accept
  Cardiocerebral Resuscitation (CCR).
• Accordingly, they were given a choice between
  passive oxygen insufflation and active
  bag-valve-mask ventilation.

9
Hypothesis

• There would be no difference in survival to
  hospital discharge for adults with OHCA receiving
  passive oxygen insufflation and those receiving
  active bag-valve-mask ventilation as part of the
  Cardiocerebral Resuscitation EMS Protocol.

10
Methods

• Observational analysis from the prospectively
  collected SHARE database
• IRB approval from the University of Arizona
• 11 EMS agencies in Arizona utilizing CCR

11
Methods Inclusion Criteria

• Age gt18 years
• Presumed cardiac etiology
• Arrest prior to EMS arrival
• No obvious signs of death or DNR/DNI

12
Methods Documentation Criteria for Airway
Management Type

• Passive oxygen insufflation
• Documented use of a NRB
• Active bag-valve-mask ventilation
• Documented use of a BVM
• Documented ventilation rate

13
Methods Outcome Measures

• Primary
• Survival to hospital discharge passive oxygen
  insufflation vs. active bag-valve-mask
  ventilation
• All patients
• Witnessed collapse with VF on EMS arrival

14
Methods Statistical Analysis

• Survival rate to hospital discharge for passive
  oxygen insufflation vs. active bag-valve-mask
  ventilation
• Chi-square analysis
• Logistic regression analysis to determine the
  survival association of victims receiving
  passive oxygen insufflation with victims
  receiving active bag-valve-mask ventilation
• A full model was adjusted for age, gender,
  location of arrest, witnessed, bystander CPR, VF
  and EMS dispatch to arrival time interval

15
Enrollment
3,329 Total OHCA
171 excluded lt 18 YOA
3,158 adult

• 874 excluded
• 673 non-cardiac
• 139 EMS witnessed
• 62 missing outcome

2,284 arrests of cardiac etiology
598 CCR
1,686 Routine ALS
206 passive
376 active
16
ResultsCharacteristics of OHCA Victims

• Characteristic Active
  (n376) Passive (n206) P Value
• Mean age, years (SD) 65.5 (15.8) 66.4
  (15.1) 0.498
• Males, (n) 67.0 (252) 71.4 (147) 0.281
• Home location, (n) 76.1 (286) 75.7 (156) 0.928
• Bystander CPR performed, (n) 42.6 (160) 35.0
  (72) 0.073
• Witnessed, (n) 45.2 (170) 44.2 (91) 0.810
• Ventricular fibrillation, (n) 31.4 (118) 35.0
  (72) 0.380
• EMS dispatch to arrival time, mean minutes
  (SD) 5.3 (2.4) 5.0 (1.8) 0.515
• Witnessed collapse to defibrillation time, mean
  minutes (SD) 13.0 (6.1) 14.3 (8.0) 0.867

SD Standard deviation
17
ResultsSurvival to Hospital Discharge from OHCA
POI
21/46
50 40 30 20 10 0
BVM
P.001
P.144
45.7
Survival to Hospital Discharge
14/77
24/206
30/376
11.7
18.2
8.0
Witnessed with VF
All Cardiac Arrests
18
Comparison of Major OutcomesOdds Ratios
Outcomes POI vs.
BVM Primary Survival to hospital discharge,
8.0 vs. 11.7 Odds ratio (95 CI) 1.7
(0.9-3.1) Survival with witnessed VF, 18.2 vs.
45.7 Odds ratio (95 CI) 5.7 (2.3-14.2)
The model is adjusted for age, gender, location,
bystander CPR, ventricular fibrillation,
witnessed, and EMS dispatch to arrival interval
19
Limitations

• Not a RCT
• Limited electronic data

20
Discussion

• Possible beneficial effects of passive oxygen
  insufflation
• Minimizes risks of hyperventilation
• May enable providers to focus on chest
  compressions and epinephrine administration
• May avoid gastric distention, vomiting and
  aspiration

21
Future Directions

• Ongoing data collection and monitoring
• Further evaluation with electronic waveform data

22
Conclusion - 1

• Overall, there was no difference in the survival
  of adults with OHCA receiving passive oxygen
  insufflation compared to those receiving active
  bag-valve-mask ventilation during Cardiocerebral
  Resuscitation in Arizona.

23
Conclusion - 2

• The survival rate of adults with witnessed VF
  OHCA was superior in victims receiving passive
  oxygen insufflation than in victims receiving
  active bag-valve-mask ventilation during
  Cardiocerebral Resuscitation in Arizona.

24
Acknowledgements

• We are grateful to all the EMS providers in the
  state of Arizona participating in the SHARE
  program
• This presentation is dedicated to the
  firefighters and paramedics who risk their lives
  everyday to save others

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Passive Oxygen Insufflation Not Worse Even When
Ventilation Was Not Excessive

• Hayes MM, Ewy GA, Anavy ND, Hilwig RW,
• Sanders AB, Berg RA, Otto CW, Kern KB
• Continuous passive oxygen insufflation results
• in a similar outcome to positive pressure
  ventilation
• in a swine model of out-of-hospital
• ventricular fibrillation
• Resuscitation. 200774(2)357-365.