Citation

Morgan P. Resuscitation 2024; ePub(ePub): ePub.

Copyright

(Copyright © 2024, Elsevier Publishing)

DOI

10.1016/j.resuscitation.2024.110157

PMID

38431074

Abstract

Drowning is the third leading cause of unintentional injury death worldwide, with an estimated 236,000 deaths annually. [1] It is defined as the process of experiencing respiratory impairment from submersion or immersion in liquid, with outcomes classed as mortality, morbidity, or no morbidity. [2] In most cases when the victim’s airway is submerged below the surface of a liquid they will attempt to hold their breath, but ultimately this breath hold will break and they will aspirate the liquid into their lungs. The presence of liquid in areas of gas exchange, increased capillary-alveolar permeability, and loss of surfactant results in an acute lung injury. The features of this acute lung injury include decreased lung compliance, atelectasis, non-cardiogenic pulmonary oedema, and hypoxaemia. It is reasonable then to assume that provision of oxygenation to the lungs via means of effective airway management and positive pressure ventilation would reverse some of effects of this process and result in return of spontaneous circulation. 3 , 4 The higher airway pressures required to ventilate the lungs following a drowning event were originally considered higher than the sealing pressures of supraglottic airway(SGA) devices, [5] however in some pre-hospital medical systems tracheal intubation (TI) is not available as an intervention so SGAs are used to good effect due to their ease of use and rapidity of insertion. 6 , 7 There is a paucity of high-level evidence as to which airway intervention is superior in these circumstances. One aspect of the scoping review by Bierens et al [8] aimed to evaluate the evidence and found no studies specifically examined the effect of a particular airway management strategy over another. Six observational studies were identified that indirectly examined airway management strategies following drowning events. In all studies TI was an indication of the severity of the injury, but there was no comprehensive adjustment for confounders. Two of these studies showed TI was associated with worse outcome, 9 , 10 and one study did not find an association between TI and survival to hospital discharge. [11] More recently Ryan et al[7] undertook a retrospective analysis of the Cardiac Arrest Registry to Enhance Survival (CARES) database between 2013 and 2018 from the United States. They found that use of SGA devices had lower odds of survival to hospital admission compared to TI (adj.OR = 0.56, 95% CI 0.42–0.76) and lower odds of survival to discharge compared to bag valve mask (BVM) use only (adj.OR = 0.40, 95% CI 0.19–0.86) when adjusted for relative ROSC timing. The authors identified the limitations of studying these populations in terms of the order of airway interventions and the variance in the severity of the initial insult, and therefore the likelihood of remaining in cardiac arrest.

Language: en