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Pre-hospital removal improves neurological outcomes in elderly patient with foreign body airway obstruction
YutakaIgarashiMD, PhD, ShojiYokoboriMD, PhD, YudaiYoshinoMD, TomohikoMasunoMD, PhD, MasatoMiyauchi MD, PhD, HiroyukiYokotaMD, PhD
Abstract
Objective
In Japan, the number of patients with foreign body airway obstruction by food is rapidly increasing with the increase in the population of the elderly and a leading cause of unexpected death. This study aimed to determine the factors that influence prognosis of these patients.
Methods
This is a retrospective single institutional study. A total of 155 patients were included. We collected the variables from the medical records and analysed them to determine the factors associated with patient outcome. Patient outcomes were evaluated using cerebral performance categories (CPCs) when patients were discharged or transferred to other hospitals. A favourable outcome was defined as CPC 1 or 2, and an unfavourable outcome was defined as CPC 3, 4, or 5.
Results
A higher proportion of patients with favourable outcomes than unfavourable outcomes had a witness present at the accident scene (68.8% vs. 44.7%, P = 0.0154). Patients whose foreign body were removed by a bystander at the accident scene had a significantly high rate of favourable outcome than those whose foreign body were removed by emergency medical technicians or emergency physician at the scene (73.7% vs. 31.8%, P < 0.0075) and at the hospital after transfer (73.7% vs. 9.6%, P < 0.0001).
Conclusions
The presence of a witness to the aspiration and removal of the airway obstruction of patients by bystanders at the accident scene improves outcomes in patients with foreign body airway obstruction. When airway obstruction occurs, bystanders should remove foreign bodies immediately.
Objective
In Japan, the number of patients with foreign body airway obstruction by food is rapidly increasing with the increase in the population of the elderly and a leading cause of unexpected death. This study aimed to determine the factors that influence prognosis of these patients.
Methods
This is a retrospective single institutional study. A total of 155 patients were included. We collected the variables from the medical records and analysed them to determine the factors associated with patient outcome. Patient outcomes were evaluated using cerebral performance categories (CPCs) when patients were discharged or transferred to other hospitals. A favourable outcome was defined as CPC 1 or 2, and an unfavourable outcome was defined as CPC 3, 4, or 5.
Results
A higher proportion of patients with favourable outcomes than unfavourable outcomes had a witness present at the accident scene (68.8% vs. 44.7%, P = 0.0154). Patients whose foreign body were removed by a bystander at the accident scene had a significantly high rate of favourable outcome than those whose foreign body were removed by emergency medical technicians or emergency physician at the scene (73.7% vs. 31.8%, P < 0.0075) and at the hospital after transfer (73.7% vs. 9.6%, P < 0.0001).
Conclusions
The presence of a witness to the aspiration and removal of the airway obstruction of patients by bystanders at the accident scene improves outcomes in patients with foreign body airway obstruction. When airway obstruction occurs, bystanders should remove foreign bodies immediately.
The International Liaison Committee on Resuscitation (ILCOR) review the evidence around the relief of upper-airway obstruction, including all methods and devices.
The peak body in the world for resuscitation science has just release a report showing the review of the evidence available for methods and devices used to relieve upper airway obstructions. A summary of the outcomes and recommendations is below. The full text is available on the ILCOR website.
Summary of ILCOR Systematic Review: Removal of Foreign Body Airway Obstruction
Created: January 02, 2020 · Updated: January 03, 2020
The International Liaison Committee on Resuscitation (ILCOR) recently conducted a systematic review of the evidence surrounding various techniques used for the removal of upper airway obstruction. The techniques included both first aid measures and equipment, including Magill forceps and suction-based airway devices (such as the LifeVac).
We suggest that abdominal thrusts are used in adults and children with a FBAO and an ineffective cough where back slaps are ineffective (weak recommendation, very low certainty of evidence).
We suggest that rescuers consider the manual extraction of visible items in the mouth (weak recommendation, very low certainty of evidence).
We suggest against the use of blind finger sweeps in patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that appropriately skilled individuals consider the use of Magill forceps to remove FBAO in OHCA patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that chest thrusts are used in unconscious patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that bystanders undertake interventions to support FBAO removal as soon as possible after recognition (weak recommendation, very low certainty of evidence).
Created: January 02, 2020 · Updated: January 03, 2020
The International Liaison Committee on Resuscitation (ILCOR) recently conducted a systematic review of the evidence surrounding various techniques used for the removal of upper airway obstruction. The techniques included both first aid measures and equipment, including Magill forceps and suction-based airway devices (such as the LifeVac).
- It is the opinion of ILCOR that foreign body airway obstruction (FBAO) is a common problem and many cases are likely to be resolved easily, without the need to involve healthcare providers. ILCOR did recognise that FBAO is however an important cause of early mortality that typically affects the young and old, or individuals with impaired neurological function / swallowing. Further that current strategies to remove FBAO are well known to many people, but all interventions can cause harm that may lead to death, as well as delays in treatment (of any kind). Therefore, there is a need to carefully balance the risks and benefits of strategies to removing foreign airway (by any means).
- Overall, the ILCOR found that all the evidence on choking management to be rated as very low quality (via the GRADE methodology they use) for all outcomes primarily due to a very serious risk of bias due to confounding. Because of this and a high degree of heterogeneity, no meta-analyses could be performed and they found all individual studies to be difficult to interpret. This was the case regardless of whether the studies concerned first aid measures or suction-based devices.
- ILCOR found evidence of harm has been reported for strategies of back blows, abdominal thrusts, chest thrusts, and blind finger sweeps but no case reports of harm were identified in relation to Magill forceps or suction-based airway clearance devices, although the number of uses is likely to be low.
- That in recent years, manual suction devices (airway clearance devices) have been developed but these devices have not previously been considered by ILCOR.
- ILCOR noted a higher level of risk with airway clearance devices which incorporate a plastic tube that is inserted in to the mouth (e.g. Dechoker), that could conceivably cause harm in a similar way to a blind finger sweep and that further evidence on safety is required.
- ILCOR found that there are reported cases of benefit for back blows, chest thrusts/ compressions, abdominal thrusts, Magill forceps, finger sweeps, and suction-based airway clearance devices. They also reported cases of harm for all interventions (except suction-based devices) i.e. back blows, chest thrusts, abdominal thrusts, and blind finger sweeps.
- The task force acknowledges that there are some data from a case series demonstrating the efficacy of suction-based airway clearance devices.
- At this time the ILCOR felt that the data were insufficient to support the implementation of a new technology with an associated financial cost. This reflects the primary function of treatment recommendations at ILCOR in regard to i.e. that measures are focused on first aid measures that can be implemented by anyone without specialised or additional equipment.
- The ILCOR noted in regard to suction-based devices, that the limited number of cases is likely insufficient to provide preliminary data on harm. On this basis, the task force felt that there was insufficient evidence to make a treatment recommendation in relation to these devices. The task force has outlined recommendations for further research in relation to these devices. The format and detail of this data reflects the detail already collected by LifeVac in post-market surveillance. i.e. accurately describe the incidence of FBAO, patient demographics (age, setting, comorbidities, food type, conscious level), full range of interventions delivered, who delivered interventions (health professional/ lay responder), success rates of interventions, harm of interventions, and outcomes. The ILCOR has noted in their report what LifeVac has been asserting for some time i.e. that it is unlikely that such a study can be conducted using only health service data.
- The ILCOR believes that there is a need for further evidence on the benefits and harms of suction-based airway clearance devices and suggested the prospective registration of all device uses and published case series. This has always been the intention of LifeVac. Importantly ILCOR made no comment regarding the limitation of use of the suction-based devices and assumed evidence would be forthcoming from health professionals and laypeople, from all demographics i.e. paediatric and adult patients.
- The treatment recommendations made by the ILCOR based on currently available evidence, re-enforce the guidance provided by LifeVac in its IFU and further discredit the divergent opinions of the Australian Resuscitation Council:
We suggest that abdominal thrusts are used in adults and children with a FBAO and an ineffective cough where back slaps are ineffective (weak recommendation, very low certainty of evidence).
We suggest that rescuers consider the manual extraction of visible items in the mouth (weak recommendation, very low certainty of evidence).
We suggest against the use of blind finger sweeps in patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that appropriately skilled individuals consider the use of Magill forceps to remove FBAO in OHCA patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that chest thrusts are used in unconscious patients with a FBAO (weak recommendation, very low certainty of evidence).
We suggest that bystanders undertake interventions to support FBAO removal as soon as possible after recognition (weak recommendation, very low certainty of evidence).