2023+AHRQ循证指南：院前气道管理.pdf

Evidence-Based Guideline for Prehospital Airway ManagementJeffrey L.Jarvisa,Ashish R.Panchalb,John W.Lyngc,Nichole Bossond,Joelle J.Donofrio-Odmanne,Darren A.Braudef,Lorin R.Browneg,Michael Arinderh,Scott Bolleteri,Toni Grossj,Michael Levyk,George Lindbeckb,Lauren M.Maloneyl,Connie J.Matterak,Cheng-Teng Wangm,Remle P.Crowen,Christopher B.Gageo,Eddy S.Langp,and J.Matthew Shollb aOffice of the Medical Director,Metropolitan Area EMS Authority,Fort Worth,Texas;bNational Registry of Emergency Medical Technicians,Columbus,Ohio;cEmergency Medicine,North Memorial Health Hospital Level 1 trauma center,Minneapolis,Minnesota;dEMS,Los Angeles County Department of Health Services,Los Angeles,California;eDepartment of Emergency Medicine,University of California San Diego,La Jolla,California;fDepartment of Emergency Medicine,The University of New Mexico,Albuquerque,New Mexico;gDepartment of Emergency Medicine,Medical College of Wisconsin,Milwaukee,Wisconsin;hEMS,Global Medical Response Inc.,Greenwood Village,Colorado;iEMS,Healthcare Innovation&Sciences Centre,Spring Branch,Texas;jDepartment of Emergency Medicine,LCMC Health,New Orleans,Louisiana;kEMS,Anchorage,Arkansas,US;lDepartment of Emergency Medicine,Stony Brook Medicine,Stony Brook,New York;mDepartment of Emergency Medicine,Robert Wood Johnson University Hospital,New Brunswick,New Jersey;nResearch,ESO Solutions Inc.,Austin,Texas;oResearch,National Registry of Emergency Medical Technicians,Columbus,Ohio;pDepartment of Emergency Medicine,Alberta Health Services,Edmonton,Canada ABSTRACT Airway management is a cornerstone of emergency medical care.This project aimed to create evi-dence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality(AHRQ).A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment,Development,and Evaluation(GRADE)methodology.The panel made specific recommendations on the different PICO(popula-tion,intervention,comparison,outcome)questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations.The recom-mendations address the use of ventilation with bag-valve mask ventilation alone vs.supraglottic airways vs.endotracheal intubation for adults and children with cardiac arrest,medical emergen-cies,and trauma.Additional recommendations address the use of video laryngoscopy and drug-assisted airway management.These recommendations,and the associated good practice statements,offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.ARTICLE HISTORY Received 11 April 2023 Revised 5 November 2023 Accepted 5 November 2023 IntroductionOne of the first reported US civilian field endotracheal intu-bations was performed in the early 1970s by John Moon,a paramedic with Freedom House Ambulance in Pittsburgh(1).Since then,airway management has expanded greatly to become foundational in prehospital emergency medical care.While there is little debate regarding the importance of pre-hospital airway management,there is less clarity surround-ing the optimal approach to maximize patient outcomes and mitigate risk of harm.Many important questions remain about the most effective approaches to prehospital airway management in different patient populations and settings.To help address the knowledge gaps in best practices for prehospital airway management,the National Highway Traffic Safety Administration(NHTSA)funded the Agency for Healthcare Research and Quality(AHRQ)to perform a systematic review of the available literature comparing approaches to prehospital airway management using struc-tured PICO(population,intervention,comparison,outcome)questions(2).To build on this systematic review,NHTSA separately funded the present work of developing a set of evi-dence-based guidelines(EBG)and recommendations through a rigorous evidence evaluation strategy(3,4).The final goal of this work is to generate evidence-based recommendations for airway management in the prehospital setting with good practice statements to facilitate the dissemination and imple-mentation of guideline recommendations.MethodsA technical expert panel composed of individuals with broad expertise in emergency and EMS medicine,education,research methods,and evidence evaluation was assembled(Table 1).The panel leveraged the established Grading of Recommendations Assessment,Development,and CONTACT Jeffrey L.Jarvis jjarvismedstar911.org Editors Note:Please see the related editorial at 10.1080/10903127.2023.2281361 and the related article at 10.1080/10903127.2023.2281377.2023 The Author(s).Published with license by Taylor&Francis Group,LLC This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License(http:/creativecommons.org/licenses/by-nc-nd/4.0/),which permits non-commercial re-use,distribution,and reproduction in any medium,provided the original work is properly cited,and is not altered,transformed,or built upon in any way.The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s)or with their consent.PREHOSPITAL EMERGENCY CARE https:/doi.org/10.1080/10903127.2023.2281363Evaluation(GRADE)methodology with rigorous recommen-dation development techniques to review the findings of the AHRQ systematic review and generate evidence-based guidelines for airway management in the prehospital setting(4).The detailed methodology,including the summary of findings tables and evidence-to-decision tables,is presented in the companion methods paper(5).Recommendations and Good Practice StatementsThe AHRQ systematic review considered three general domains:indication for airway management,patient age,and device type.The panel generated practice recommenda-tions for each combination of these domains based on the PICO questions and evidence from the AHRQ review.These recommendations were consistent with the GRADE method-ology and the process met the seven criteria discussed by the GRADE working group(6).To aid with implementation into practice,recognizing that these recommendations often work together when mak-ing patient care decisions,the panel summarized and opera-tionalized the recommendations for each indication and age group with good practice statements(7)(Appendix A).These good practice statements are written from the perspective of the clinicians,who often only have the patients age(adult or pediatric)and condition to make decisions on airway and ventilatory management choices(bag-valve-mask(BVM),supraglottic airway(SGA),or endotracheal intubation(ETI).The good practice state-ments leverage each developed recommendation,anchored in the evidence,to describe the best prehospital airway man-agement approach for each age group and condition.This document focuses on the good practice statements developed in conjunction with the evidence-based recommendations.In this evidence-based guideline,the panel provides 22 rec-ommendations derived from the AHRQ-reviewed literature using a robust and transparent methodology(Tables 25).Out-of-Hospital Cardiac ArrestRecommendation 1:We suggest that either ventilation with BVM alone or SGA may be used in airway management for adults with out-of-hospital cardiac arrest(OHCA)(condi-tional recommendation/very low certainty of evidence)There is inadequate evidence to support the superiority of either BVM ventilation alone or SGA for airway manage-ment in adults with OHCA.Data from three randomized controlled trials(RCT)showed equivalence in survival,and Table 1.Members of the technical expert panel.NameAffiliationExpertiseMichael ArinderAmerican Ambulance AssociationParamedic,educatorScott BolleterCentre for Emergency Health SciencesParamedic,educator,researcherNichole BossonNational Association of EMS PhysiciansEM and EMS physicianDarren BraudeNational Association of EMS PhysiciansEM and EMS physicianLorin R.BrowneNational Association of EMS PhysiciansPediatric EM and EMS physicianRemle CroweESOResearcher,methodologistJoelle DonofrioNational Association of EMS PhysiciansEM,pediatric,and EMS physicianToni GrossNational Association of EMS PhysiciansEM,pediatric,and EMS physicianJeff JarvisNEMSQAEM and EMS physicianEddy LangNational Association of EMS PhysiciansEM and EMS physician,researcher,methodologistMike LevyNational Association of EMS PhysiciansEM and EMS physicianGeorge LindbeckNational Association of State EMS OfficialsEM and EMS physicianJohn LyngNational Association of EMS PhysiciansEM and EMS physicianLauren MaloneyNational Association of EMS PhysiciansEM and EMS physicianConnie MatteraNational Association of EMS EducatorsEMS educatorNick NudellThe Paramedic FoundationParamedicAshish R.PanchalNational Registry of EMTsEM and EMS physician,researcher,methodologistMatt ShollNational Association of State EMS OfficialsEM and EMS physicianCheng-Teng“Bill”WangNational EMS Quality AllianceEM and EMS physicianCo-principal investigator.Project methodologist.Table 2.Recommendations for airway management during out of hospital cardiac arrest.RecommendationStrengthCertainty of evidenceAdultWe suggest that either BVM alone or SGA may be used in airway management for adults with OHCA.Conditional recommendationVery lowWe suggest that either ventilation with BVM alone or ETI may be used in airway management for adults with OHCA.Conditional recommendationLow1.We suggest in favor of SGA over ETI in airway management for adults in OHCA in systems without demonstrated high ETI proficiency.2.We suggest either SGA or ETI may be used in airway management for adults in OHCA in systems with demonstrated high ETI proficiency.Conditional recommendationLow-moderatePediatricWe suggest that either BVM or SGA may be used in airway management for pediatric patients with OHCA.Conditional recommendationVery lowWe suggest in favor of ventilation with BVM alone over ETI in airway management for pediatric patients with OHCA.Conditional recommendationLowWe suggest in favor of SGA over ETI in airway management for pediatric patients with OHCA.Conditional recommendationVery low2J.L.JARVIS ET AL.multiple observational studies showed no difference in rates of return of spontaneous circulation(ROSC)(823).Contrary to this,the PART trial,an RCT of SGA vs.ETI,had an as-treated subgroup analysis of BVM ventilation vs.SGA that showed improved neurologic function with BVM ventilation(10).This subgroup analysis was limited by base-line differences and indication bias,limiting the ability to generalize the results.As a result,the panel recommends using either BVM ventilation alone or SGA.The panel did,however,recognize that effective BVM ventilations often require more clinicians than effective ventilations with SGA.As a result,resource availability may appropriately influence the decision to use an SGA over BVM ventilation alone.Recommendation 2:We suggest that either ventilation with BVM alone or SGA may be used in airway manage-ment for pediatric patients with OHCA(conditional rec-ommendation/very low certainty of evidence)There was no convincing evidence for the superiority of either BVM ventilation alone or SGA in pediatric patients with OHCA.The AHRQ systematic review identified two observational studies that reported the outcome of survival with one also reporting on the effect on ROSC and neuro-logically intact survival(24,25).No difference was noted for survival or ROSC,but improved neurological function was noted with BVM ventilation(25).However,due to the observational nature of this study,there was a concern for indication bias since patients who achieve ROSC quickly may not have the opportunity for an advanced airway,thus favoring BVM ventilation.Additionally,using an SGA as a rescue device after a failed airway may have favored BVM ventilation.Therefore,the panel could not draw conclusions based on this evidence but did,however,recognize that effective BVM ventilations often require more clinicians than effective ventilations with SGA.As a result,resource availability may appropriately influence the decision to use an SGA over BVM ventilation.Recommendation 3:We suggest that either ventilation with BVM alone or ETI may be used in airway manage-ment for adults with OHCA(conditional recommenda-tion/low certainty of evidence)There was no clear evidence favoring ventilation with either BVM alone or ETI in adult OHCA.One RCT of Table 3.Recommendations for airway management of patients with traumatic injuries.RecommendationStrengthCertainty of evidenceAdultWe suggest that either BVM alone or SGA may be used in airway management for adults with trauma.Conditional recommendationVery lowWe suggest that either ventilation with BVM alone or ETI may be used in airway management for adults with trauma.Conditional recommendationLowWe suggest that either SGA or ETI may be used in airway management for adults with trauma.Conditional recommendationVery lowPediatricWe found insufficient evidence to make a recommendation on the use of BVM alone compared with SGA for pediatric patients with trauma.No recommendationWe suggest that either ventilation with BVM alone or ETI may be used in airway management of pediatric patients with trauma.Conditional recommendationLowWe suggest in favor of SGA over ETI in airway management for pediatric patients with trauma.Conditional recommendationVery lowTable 4.Recommendations for airway management of patients with medical emergencies.RecommendationStrengthCertainty of evidenceAdultWe found insufficient evidence to make a recommendation on the use of BVM alone compared with SGA for adults with medical emergencies.No recommendationWe found insufficient evidence to make a recommendation on the use of BVM alone compared with ETI for adults with medical emergencies.No recommendationWe suggest that either SGA or ETI may be used in airway management for adults with medical emergencies.Conditional recommendationVery lowPediatricWe found insufficient evidence to make a recommendation on the use of BVM alone compared with SGA for pediatric patients with medical emergencies.No recommendationWe found insufficient evidence to make a recommendation on the use of BVM alone compared with ETI for pediatric patients with medical emergencies.No recommendationWe suggest that either SGA or ETI may be used in airway management for pediatric patients with medical emergencies.Conditional recommendationVery lowTable 5.Recommendations for airway management of patients using technique modifiers.RecommendationStrengthCertainty of evidenceIn patients requiring medication-assisted airway management,we suggest rapid sequence induction over no-medication approaches to facilitate airway placement under specific conditions,but only in well-resourced and high-functioning settings.Conditional recommendationVery lowIn patients requiring medication-assisted