ORIGINAL ARTICLE
Heart, Lung and Circulation (2015) 24, 241–249 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.09.004
Effective Pre-hospital Care for Out-of-hospital Cardiac Arrest Caused by Respiratory Disease Tatsuma Fukuda, M.D. *, Naoko Fukuda-Ohashi, M.D., Kent Doi, M.D., Ph.D., Takehiro Matsubara, M.D., Ph.D., Naoki Yahagi, M.D., Ph.D. Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan Received 21 June 2014; received in revised form 30 August 2014; accepted 13 September 2014; online published-ahead-of-print 28 September 2014
Background
The relationship between pre-hospital care and the prognosis of out-of-hospital cardiac arrest (OHCA) caused by respiratory disease is unclear. This study aimed to assess the impact of pre-hospital care on the prognosis of OHCA caused by respiratory disease.
Methods
In a nationwide, population-based, observational study, we enrolled 121,081 adults aged 18 years who experienced OHCA from January 1, 2010, to December 31, 2010. The primary endpoint was favourable neurological outcomes.
Results
Of the 120,256 eligible adult OHCA patients, 7,071 (5.9%) experienced OHCA caused by respiratory disease. Of these 7,071 patients, 3,911 (55.3%) received no cardiopulmonary resuscitation (CPR), 2,403 (34.0%) received chest-compression-only CPR, and 757 (10.7%) received conventional CPR by a bystander. There was no significant difference between the three types of bystander CPR with regard to the neurological outcome (no CPR: OR 0.68, 95%CI 0.39-1.24, p = 0.1951; chest-compression-only CPR: OR 0.68, 95%CI 0.37-1.29, p = 0.2295; and conventional CPR: as a reference). Pre-hospital administration of epinephrine (OR 0.37, 95%CI 0.13-0.85, p = 0.0170) and the implementation of advanced airway management (OR 0.32, 95%CI 0.19-0.52, p < 0.0001) were associated with poor neurological outcomes.
Conclusions
Even in OHCA caused by respiratory disease, not only pre-hospital epinephrine administration but also pre-hospital advanced airway management and rescue breathing in bystander CPR may not be critical.
Keywords
Out-of-hospital cardiac arrest Respiratory disease Prehospital care Cardiopulmonary resuscitation Rescue breathing Advanced airway management
Introduction Although the rate of survival after out-of-hospital cardiac arrest (OHCA) has been increasing with advances in care
throughout the ‘‘chain of survival’’, which comprises early access to emergency medical care, early cardiopulmonary resuscitation (CPR), rapid defibrillation, early advanced life support, and integrated post-cardiac arrest care [1], it is still
*Corresponding author at: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. Tel.: +81 3 3815 5411; fax: +81 3 3814 6446, Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
242
relatively low [1–3]. The neurological outcomes are far worse. Prognoses are especially poor with OHCA of non-cardiac origin [4–7]. In previous studies, the relationship between the prognosis of OHCA and pre-hospital care, including the type of bystander CPR, advanced airway management, epinephrine administration, and the use of a public-access automated external defibrillator (AED), has been examined [8–15]. However, studies have often focussed on OHCA with cardiac origin, and no study has thus far solely focussed on OHCA caused by respiratory disease. The importance of the different treatments in pre-hospital care and, in particular, the respiratory management treatments may differ between OHCA due to respiratory disease and that from other causes. This study aims at investigating the relationship between the prognosis and pre-hospital care in cases of OHCA caused by respiratory disease using the All-Japan Utstein Registry database.
Materials and Methods Study Design and Participants The All-Japan Utstein Registry of the Fire and Disaster Management Agency (FDMA) is a prospective, nationwide, population-based registry system of all OHCA patients, involving Utstein-style data collection [16]. This study was a population-based cohort study using data from the AllJapan Utstein Registry. This study included all adults aged 18 years with OHCA caused by respiratory disease and for whom resuscitation was attempted by emergency medical service (EMS) personnel with subsequent transport to medical institutions from January 1, 2010 to December 31, 2010. Patients were excluded from the analysis if data on the onset date, call receipt time, hospital arrival time, airway management status, or the usage status of a public access AED were missing or unknown. Patients who were provided only AED or ventilation by a bystander were also excluded. This study was conducted in accordance with the amended Declaration of Helsinki. The FDMA and the Institutional Review Board of The University of Tokyo approved the study with waiver of informed consent because of the anonymous nature of the data (No. 10096).
Study Setting Japan has an area of approximately 378,000 km2 and is comprised of 47 prefectures [17]. The population of Japan was approximately 128 million in 2010, with approximately 107 million people aged 18 years [17]. The EMS system in Japan has been described previously [8–15,18–20]. In 2010, the Japanese municipal governments provided EMS through 802 fire stations with dispatch centres [21]. All EMS personnel performed CPR according to the Japanese CPR guidelines, which are based on guidelines set by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) [22–24]. In
T. Fukuda et al.
most cases, an ambulance crew consisted of three EMS personnel, including at least one emergency lifesaving technician who had completed extensive training. Some of these emergency lifesaving technicians were authorised to secure infusion lines, administer epinephrine, perform endotracheal intubation, perform defibrillation, and lead CPR. Advance directives, living wills, or do-not-attempt-resuscitation orders were not generally accepted in Japan. EMS providers in Japan were not allowed to terminate resuscitation out of hospital except for specific situations, such as decapitation, rigor mortis, livor mortis, or decomposition. Therefore, most patients who had an OHCA treated by EMS personnel were transported to an emergency hospital [8,9,18–20,22].
Data Collection and Quality Control Data were collected prospectively using an Utstein-style data form that included questions on patient sex, age, aetiology of arrest, bystander witness status, bystander CPR status, initial cardiac rhythm, use of a public-access AED, presence of an emergency lifesaving technician or physician in the ambulance, administration of epinephrine, and the type of airway management technique conducted. Cardiac arrest was defined as the end of cardiac mechanical activity determined by the absence of signs of circulation [16,25]. Bystander CPR was defined as CPR performed by a person who was not responding as part of an organised emergency response system approach to an OHCA patient [16,21,22]. The aetiology of arrest was categorised as cardiac or non-cardiac by the attending physicians in the emergency department in collaboration with EMS personnel on the basis of several pieces of information such as witness information, clinical course, past history, physical findings, and examination findings. Non-cardiac causes were subdivided into respiratory disease, cerebrovascular disease, malignant tumour, external causes (such as trauma, drowning, burn, asphyxia, intoxication) or other non-cardiac causes. The aetiology of arrest was presumed to be cardiac unless evidence suggested a non-cardiac cause [16,21,22]. A series of EMS times of call receipt, vehicle arrival at the scene, contact with patients, initiation of CPR, and hospital arrival were recorded based on the clock used by each EMS system. Outcome measures included return of spontaneous circulation (ROSC) before hospital arrival, one-month survival, and neurological status one month after the event. To collect one-month follow up data, the EMS personnel in charge of each patient with OHCA queried the medical control director at the hospital. The neurological status of the patient was determined by the attending physician caring for the patient. The EMS received a written response. At this time, the aetiology of the arrest was reconfirmed. If the patient was not at the hospital, the EMS personnel conducted a follow-up examination. Data forms were completed by the EMS personnel in charge of each patient, and the data were integrated into the Utstein registry system on the FDMA database server. Forms were logically checked by the computer system and
243
Effective care in respiratory OHCA
were confirmed by the FDMA. If the data form was incomplete, the FDMA returned it to the respective fire station, and the data were then reconfirmed.
Study Endpoints The primary endpoint was a favourable neurological outcome one month after cardiac arrest, defined a priori as a Glasgow-Pittsburgh cerebral performance category 1 (good performance) or 2 (moderate disability) [16]. The other categories of 3 (severe cerebral disability), 4 (vegetative state), and 5 (death) were regarded as unfavourable neurological outcomes [16]. Secondary outcome measures were the one-month survival and the ROSC before hospital arrival.
Statistical Analysis The total sample size in this nationwide, population-based study was determined by the number of patients obtained from the All-Japan Utstein Registry database in 2010. Continuous variables were assessed by analysis of variance (ANOVA), and categorical variables were assessed by the x2 test. Simple regression analysis was used to assess the relationship between predictor variables and each of the three endpoints. Multivariate logistic regression analysis was performed to examine the favourable outcomes of each type of pre-hospital care. Odds ratios (OR) and 95% confidence intervals (CI) were calculated while adjusting for potential confounding factors including sex, age, the witness status, the
bystander CPR status, the initial cardiac rhythm, use of a public access AED, the presence of a physician in the ambulance, the administration of epinephrine, advanced airway management, and time from the call to hospital arrival. All statistical analyses were conducted using JMP Pro 10.0.2 (SAS Institute Inc., Cary, NC, USA). All tests were two-tailed, and p values of
Heart, Lung and Circulation (2015) 24, 241–249 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.09.004
Effective Pre-hospital Care for Out-of-hospital Cardiac Arrest Caused by Respiratory Disease Tatsuma Fukuda, M.D. *, Naoko Fukuda-Ohashi, M.D., Kent Doi, M.D., Ph.D., Takehiro Matsubara, M.D., Ph.D., Naoki Yahagi, M.D., Ph.D. Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan Received 21 June 2014; received in revised form 30 August 2014; accepted 13 September 2014; online published-ahead-of-print 28 September 2014
Background
The relationship between pre-hospital care and the prognosis of out-of-hospital cardiac arrest (OHCA) caused by respiratory disease is unclear. This study aimed to assess the impact of pre-hospital care on the prognosis of OHCA caused by respiratory disease.
Methods
In a nationwide, population-based, observational study, we enrolled 121,081 adults aged 18 years who experienced OHCA from January 1, 2010, to December 31, 2010. The primary endpoint was favourable neurological outcomes.
Results
Of the 120,256 eligible adult OHCA patients, 7,071 (5.9%) experienced OHCA caused by respiratory disease. Of these 7,071 patients, 3,911 (55.3%) received no cardiopulmonary resuscitation (CPR), 2,403 (34.0%) received chest-compression-only CPR, and 757 (10.7%) received conventional CPR by a bystander. There was no significant difference between the three types of bystander CPR with regard to the neurological outcome (no CPR: OR 0.68, 95%CI 0.39-1.24, p = 0.1951; chest-compression-only CPR: OR 0.68, 95%CI 0.37-1.29, p = 0.2295; and conventional CPR: as a reference). Pre-hospital administration of epinephrine (OR 0.37, 95%CI 0.13-0.85, p = 0.0170) and the implementation of advanced airway management (OR 0.32, 95%CI 0.19-0.52, p < 0.0001) were associated with poor neurological outcomes.
Conclusions
Even in OHCA caused by respiratory disease, not only pre-hospital epinephrine administration but also pre-hospital advanced airway management and rescue breathing in bystander CPR may not be critical.
Keywords
Out-of-hospital cardiac arrest Respiratory disease Prehospital care Cardiopulmonary resuscitation Rescue breathing Advanced airway management
Introduction Although the rate of survival after out-of-hospital cardiac arrest (OHCA) has been increasing with advances in care
throughout the ‘‘chain of survival’’, which comprises early access to emergency medical care, early cardiopulmonary resuscitation (CPR), rapid defibrillation, early advanced life support, and integrated post-cardiac arrest care [1], it is still
*Corresponding author at: Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. Tel.: +81 3 3815 5411; fax: +81 3 3814 6446, Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
242
relatively low [1–3]. The neurological outcomes are far worse. Prognoses are especially poor with OHCA of non-cardiac origin [4–7]. In previous studies, the relationship between the prognosis of OHCA and pre-hospital care, including the type of bystander CPR, advanced airway management, epinephrine administration, and the use of a public-access automated external defibrillator (AED), has been examined [8–15]. However, studies have often focussed on OHCA with cardiac origin, and no study has thus far solely focussed on OHCA caused by respiratory disease. The importance of the different treatments in pre-hospital care and, in particular, the respiratory management treatments may differ between OHCA due to respiratory disease and that from other causes. This study aims at investigating the relationship between the prognosis and pre-hospital care in cases of OHCA caused by respiratory disease using the All-Japan Utstein Registry database.
Materials and Methods Study Design and Participants The All-Japan Utstein Registry of the Fire and Disaster Management Agency (FDMA) is a prospective, nationwide, population-based registry system of all OHCA patients, involving Utstein-style data collection [16]. This study was a population-based cohort study using data from the AllJapan Utstein Registry. This study included all adults aged 18 years with OHCA caused by respiratory disease and for whom resuscitation was attempted by emergency medical service (EMS) personnel with subsequent transport to medical institutions from January 1, 2010 to December 31, 2010. Patients were excluded from the analysis if data on the onset date, call receipt time, hospital arrival time, airway management status, or the usage status of a public access AED were missing or unknown. Patients who were provided only AED or ventilation by a bystander were also excluded. This study was conducted in accordance with the amended Declaration of Helsinki. The FDMA and the Institutional Review Board of The University of Tokyo approved the study with waiver of informed consent because of the anonymous nature of the data (No. 10096).
Study Setting Japan has an area of approximately 378,000 km2 and is comprised of 47 prefectures [17]. The population of Japan was approximately 128 million in 2010, with approximately 107 million people aged 18 years [17]. The EMS system in Japan has been described previously [8–15,18–20]. In 2010, the Japanese municipal governments provided EMS through 802 fire stations with dispatch centres [21]. All EMS personnel performed CPR according to the Japanese CPR guidelines, which are based on guidelines set by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) [22–24]. In
T. Fukuda et al.
most cases, an ambulance crew consisted of three EMS personnel, including at least one emergency lifesaving technician who had completed extensive training. Some of these emergency lifesaving technicians were authorised to secure infusion lines, administer epinephrine, perform endotracheal intubation, perform defibrillation, and lead CPR. Advance directives, living wills, or do-not-attempt-resuscitation orders were not generally accepted in Japan. EMS providers in Japan were not allowed to terminate resuscitation out of hospital except for specific situations, such as decapitation, rigor mortis, livor mortis, or decomposition. Therefore, most patients who had an OHCA treated by EMS personnel were transported to an emergency hospital [8,9,18–20,22].
Data Collection and Quality Control Data were collected prospectively using an Utstein-style data form that included questions on patient sex, age, aetiology of arrest, bystander witness status, bystander CPR status, initial cardiac rhythm, use of a public-access AED, presence of an emergency lifesaving technician or physician in the ambulance, administration of epinephrine, and the type of airway management technique conducted. Cardiac arrest was defined as the end of cardiac mechanical activity determined by the absence of signs of circulation [16,25]. Bystander CPR was defined as CPR performed by a person who was not responding as part of an organised emergency response system approach to an OHCA patient [16,21,22]. The aetiology of arrest was categorised as cardiac or non-cardiac by the attending physicians in the emergency department in collaboration with EMS personnel on the basis of several pieces of information such as witness information, clinical course, past history, physical findings, and examination findings. Non-cardiac causes were subdivided into respiratory disease, cerebrovascular disease, malignant tumour, external causes (such as trauma, drowning, burn, asphyxia, intoxication) or other non-cardiac causes. The aetiology of arrest was presumed to be cardiac unless evidence suggested a non-cardiac cause [16,21,22]. A series of EMS times of call receipt, vehicle arrival at the scene, contact with patients, initiation of CPR, and hospital arrival were recorded based on the clock used by each EMS system. Outcome measures included return of spontaneous circulation (ROSC) before hospital arrival, one-month survival, and neurological status one month after the event. To collect one-month follow up data, the EMS personnel in charge of each patient with OHCA queried the medical control director at the hospital. The neurological status of the patient was determined by the attending physician caring for the patient. The EMS received a written response. At this time, the aetiology of the arrest was reconfirmed. If the patient was not at the hospital, the EMS personnel conducted a follow-up examination. Data forms were completed by the EMS personnel in charge of each patient, and the data were integrated into the Utstein registry system on the FDMA database server. Forms were logically checked by the computer system and
243
Effective care in respiratory OHCA
were confirmed by the FDMA. If the data form was incomplete, the FDMA returned it to the respective fire station, and the data were then reconfirmed.
Study Endpoints The primary endpoint was a favourable neurological outcome one month after cardiac arrest, defined a priori as a Glasgow-Pittsburgh cerebral performance category 1 (good performance) or 2 (moderate disability) [16]. The other categories of 3 (severe cerebral disability), 4 (vegetative state), and 5 (death) were regarded as unfavourable neurological outcomes [16]. Secondary outcome measures were the one-month survival and the ROSC before hospital arrival.
Statistical Analysis The total sample size in this nationwide, population-based study was determined by the number of patients obtained from the All-Japan Utstein Registry database in 2010. Continuous variables were assessed by analysis of variance (ANOVA), and categorical variables were assessed by the x2 test. Simple regression analysis was used to assess the relationship between predictor variables and each of the three endpoints. Multivariate logistic regression analysis was performed to examine the favourable outcomes of each type of pre-hospital care. Odds ratios (OR) and 95% confidence intervals (CI) were calculated while adjusting for potential confounding factors including sex, age, the witness status, the
bystander CPR status, the initial cardiac rhythm, use of a public access AED, the presence of a physician in the ambulance, the administration of epinephrine, advanced airway management, and time from the call to hospital arrival. All statistical analyses were conducted using JMP Pro 10.0.2 (SAS Institute Inc., Cary, NC, USA). All tests were two-tailed, and p values of
