Waarom beademen belangrijk is. 2-3x beter! Overleving Arrest Noord-Holland. Overleving in Europa

30-3-2015

Waarom beademen belangrijk is


Overleving Arrest Noord-Holland

Waarom beademen belangrijk is 60% 50%

Ruud Koster Academisch Medisch Centrum Amsterdam

40% 30% 20% 10% 0% 1995

2006

Totale overleving


2007

2008

2009

Overleving bij schokbaar 1e ritme

2010

2011

2012

2013

Overleving bij geen schokbaar 1e ritme


Overleving in Europa Hoe komt de overleving in Nederland zo hoog? 10 25

11

• Grote bereidheid BLS uit te voeren • Snelle en goede acceptatie van de AED • Kwaliteit van BLS onderwijs, al 40 jaar lang!

7 22

?

? 3 5 ? ? 10



Basale reanimatie in Europa

Overleving na reanimatie wereldwijd Statistische analyse:

48

Overleving met BLS

50

6-10

7-10

2-7

44 30 60

37

2-3x beter!

50 25

19

10-13 15 5

10

1

30-3-2015


Probleem groot in de USA: weinig BLS


Compression-only CPR

Wat zouden de redenen kunnen zijn?

1. Weinig hulpverleners kunnen ventileren 2. Veel hulpverleners doen geen BLS omdat ze geen mond-op-mond beademing willen doen 3. Geen BLS uit angst voor juridische aansprakelijkheid? 4. Beademingen onderbreken de borstcompressies


• Gebaseerd op jaren dieronderzoek in Tucson (Arizona) • Beademing geen voordeel • Onderbreking compressies nadelig


AHA takes position

Retrospectieve analyse van oude gegevens



Retrospectieve analyse van oude gegevens

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30-3-2015



Omstander BLS

Geen BLS willen doen? 1. Herkenning hartstilstand– 65%

Land

Omstander BLS

Japan (Iwami)

1998-2003: 27%

Japan (SOS-Kanto)

2002-2003: 29%

USA (Bobrow)

2005-2009: 34%

USA (Weisfeldt)

2005-2007: 32%

USA, Seattle (Rea)

1980: 22%; 2000: 50%

Zweden (Bohm)

1992: 31%; 2005: 50%

Noorwegen (Olasveengen)

2007: 59%%

Denemarken (Wissenberg)

2010: 45%

Nederland (Waalewijn/Berdowski)

1995: 53%; 2010: >70%

2. Omstander kan het fysiek niet – 20%

(Te emotioneel - <10%) Swor Acad Emerg Med 2006


Geen BLS willen doen? 1. Herkenning hartstilstand– 65% 2. Omstander kan het fysiek niet – 20%

(Patient te onsmakelijk – <2%)


Waarom zouden burgers moeten leren beademen? • Als je het leert, ben je nog niet verplicht om het te doen • Als je het niet leert – zal je het nooit kunnen doen

(Te emotioneel - <10%) Swor Acad Emerg Med 2006

(Patient te onsmakelijk – <2%)


Waarom zouden burgers moeten leren beademen?


Hoe lang kunnen we zonder zuurstof?

• Als je het leert, ben je nog niet verplicht om het te doen • Als je het niet leert – zal je het nooit kunnen doen

• Zuurstof en beademing is nodig – Altijd voor niet-cardiale oorzaken van een arrest – Altijd voor kinderen – Meestal voor arrest met een cardiale oorzaak

3

30-3-2015

Waarom beademen belangrijk is Meursing JACC 1983: 6 honden (alleen abstract)


Zuurstof is verbruikt <2-3 minuten

Dorph Resuscitation 2004

Turner Resuscitation 2002

Ambulance aankomsttijd 6-10 minuten


Human evidence

Waarom beademen belangrijk is Compression-only CPR vs. Standard CPR (Bohm 2007)

Is de overleving werkelijk “similar”?


Early: ≤8 minutes

Waarom beademen belangrijk is Compression-only CPR vs. Full CPR (Bohm 2007)

Late: >8 minutes Electrical phase

Circulatory phase

Metabolic phase

Three-phase model

4

30-3-2015





What CPR is delivered?


45

45

40

40

35

35

% CPR delivered

25 CO CPR

20

30

Survival

30

Survival

% CPR delivered

25

CO CPR

20

Full CPR

15

All CPR

15 10

10

5

5

0

0 2005

2006

2007

2008

2009

2005


45

40

40

2009

35

30

Survival

2008


45 35

% CPR delivered

30

25

CO CPR

25

CO CPR

20

Full CPR

20

Full CPR

15

All CPR

15

All CPR

10

10

5

5

0

0 2005

2006

2007

2008

2009

2005

2006

Survival

2007

2008

2009

Survival

12,0

12,0

10,0

10,0

In >30% was informatie over functionele uitkomst onbekend

8,0

6,0

Survival

Survival

8,0

Survival

2007



% CPR delivered

2006

4,0

2,0

2,0

0,0

Survival

6,0

4,0

CPC 1+2

0,0 2005

2006

2007

2008

2009

2005

2006

2007

2008

2009

5

30-3-2015

Waarom beademen belangrijk is Uitkomst

Geen BLS

Waarom beademen belangrijk is CC + ventilatie

Comp only BLS

Goed: CPC 1+2 (%)

3.0

5.2

7.9 (+2.7%)

Slecht: CPC 3+4 (%)

0.6

0.5

3.0 (+2.5%)

Is dit de toekomst?

100% 80% CPC 1+2 CPC 3+4

60% 40% 20%

0% Bobrow JAMA 2010

No CPR

CC + vent

Comp only CPR

Waarom beademen belangrijk is Dit heeft zijn waarde bewezen


Nederland zit in de top 3 van de wereld! Dank zij goede omstander BLS

10 25 11

7 22

?

3

?

5 ? ? 10

Waarom beademen belangrijk is Leer en stimuleer borstcompressies met beademing


Discussie

Er is geen snellere weg naar goede reanimatie!

6

30-3-2015



For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compressiononly CPR is similarly effective.

This nationwide observational study indicates that rescue breathing has an incremental benefit for OHCAs of noncardiac origin, but the impact on the overall survival after OHCA was small.


2005


The formula of Survival

Conventional CPR

We have to deal mainly with cardiac cases in need for CPR. So…

CC only CPR


CC only CPR Full CPR

Effective

(Knowledge)

0.9

Medical Science

Medical Science

0.8

0.4

0.2

X

=

Survival

=

Survival

0.07

Medical Science

Effective

Local

(Knowledge)

Education

Implementation

0.5

0.8

X

X

0.5

0.20

=

Survival

0.07

0.5

=

Survival

=

Survival

0.20

triples! • • • • •

Bystander CPR doubles survival Bystander CPR is needed for 5-10 minutes Arterial oxygen supply lasts 2-3 minutes Education remains critical In class teach full CPR – C:V 30:2

Local

Education X

0.2

Implementation X

Effective

(Knowledge)

0.9

0.8

X

Teach good bystander CPR – it helps!

Local

Education X

0.9

Implementation X

Effective

(Knowledge)

0.5

0.4

Implementation

Local

Education X

Local

Education


The formula of Survival: which is the best choice?

Medical Science

Effective

(Knowledge)

The formula of Survival

the important question then is….

Conventional CPR

Medical Science

Implementation X

0.6

0.43

7

30-3-2015


Optimal C:V ratio (ventilation 15 s)


Lancet CC only 1

Table 2

Avg. survival 42/604 = 6.9% Avg. survival 15/447 = 3.3%

Table 3

Babbs, Resuscitation 2002



Who did CPR?

Lancet CC only 2

Survival by provider CPR by Lay person Off-duty medical worker


CO CPR

Full CPR

OR (C.I.)

Average

23/342 (7%)

19/362 (5%)

1.3 (0.7-2.4)

42/704 (6.0%)

4/97 (4%)

11/350 (3%)

1.3 (0.4-4.3)

15/447 (3.4%)


Who did CPR? Survival by provider CPR by Lay person

CO CPR

Full CPR

OR (C.I.)

Average

23/342 (7%)

19/362 (5%)

1.3 (0.7-2.4)

42/704 (6.0%)

4/97 (4%)

11/350 (3%)

1.3 (0.4-4.3)

15/447 (3.4%)

Off-duty medical worker

Evenly distributed? CPR by

CO CPR (n=439)

Full CPR (n=712)

Lay person

342 (78%)

362 (51%)

Off-duty medical worker

97 (22%)

350 (49%)

confounder:

Not superior, therefore equal or “similar”? “difference not proven” ≠ “treatments are equal”

Non-inferiority analysis would not have rejected inferiority

–Covariate, not related to variable of interest (compression only resuscitation) –Determinant of outcome (survival) –Unevenly distributed among groups

8

30-3-2015



New discussion 2008


Survival after cardiac arrest Study (outcome)

“standard” = CC en MMV

CC only

RR (95% CI)

Nagao 2002-2003 (Japan) (30 days, good neurologic)

4%

6%

1.5 (0.9-2.5)

Bohm 1990-2005(Sweden) (1 month, good neurologic)

7.2

6.7

0.93 (0.74-1.17)

Iwami 1998-2003 (Japan) (1 year, good neurologic)

3.6

3.5

0.97 (0.55-1.73)

Bobrow 2005-2007 (USA) (survival to discharge)

1.8

5.4

2.94 (1.06-8.16)

Waarom beademen belangrijk is ERC Richtlijnen 2010 •

Recommendations

•

Follow the ERC Guidelines 2010 Teach full CPR with ventilations Do full CPR with ventilations

•

AHA Richtlijnen 2010 • …. • Als borstcompressies zijn gestart, moet een getrainde hulpverlener ook mond-op-mond beademen of met een ballon • Gebruik een C:V verhouding van 30 borstcompressies op 2 ventilaties

Recommend CO CPR for: not willing or able to do ventilations telephone instructed CPR


Alle hulpverleners, met en zonder training, moeten borstcompressies geven aan slachtoffers van een hartstilstand. Getrainde hulpverleners moeten ook beademen met een compressie–ventilatie (CV) verhouding 30:2. Telefoon-instructies doen BLS met alleen borstcompressies voor omstanders zonder training.

Waarom beademen belangrijk is Type of CPR

2005

2006

2007

2008

2009

none

72%

67%

68%

64%

60%

full

23%

17%

17%

12%

10%

CC only

5%

15%

15%

23%

30%

change

9

30-3-2015



Type of CPR

2005

2006

2007

2008

2009

change

Type of CPR

2005

2006

2007

2008

2009

change

none

72%

67%

68%

64%

60%

-12%

none

72%

67%

68%

64%

60%

-12%

full

23%

17%

17%

12%

10%

-13%

full

23%

17%

17%

12%

10%

-13%

CC only

5%

15%

15%

23%

30%

+25%

CC only

5%

15%

15%

23%

30%

+25%

3.7%

7.2%

6.7%

6.6%

9.8%

+6.1%

Overall survival


Waarom beademen belangrijk is Is CO CPR the better way?

Gordon Ewy Circulation 2008:


1. Scientific evidence remains on low level 2. Severe methodological problems in the design and analysis 3. The only effectiveness study shows modest increase in bystander CPR but no overall benefit of a relevant outcome 4. Compression only CPR is not suitable for children and for patients with a respiratory cause


Wat is de vraag van het onderzoek?

Recommendations • Therapie onderzoek: – Meestal “nieuw middel is beter dan oud middel” • Bewijs: significant beter b.v. nieuw tenminste 10% beter

– Soms “nieuw middel is gelijk aan oud middel” • Bewijs: nieuw niet significant slechter dan oud b.v. nieuw maximaal 10 % slechter

• • • • •

Do CPR – it helps Teach good chest compressions After 2-3 minutes of CPR oxygen is needed Teach ventilations Use AED’s for early defibrillation!

• Evaluate all evidence at ILCOR 2010

10

30-3-2015



Type of CPR

2005

2006

2007

2008

2009

change

none

72%

67%

68%

64%

60%

-12%

full

23%

17%

17%

12%

10%

-13%

CC only

5%

15%

15%

23%

30%

+25%

Overall survival

3.7%

7.2%

6.7%

6.6%

9.8%

+6.1%

Neuro intact survival

2,4%

5,5%

4,7%

4,2%

3,6%

+1.2%

Off-duty medical personnel

•Requirements for effectiveness study: •Interventions in the real world •All patients in the community accounted for •Meaningful outcome


Overall CC and outcome ventilation 6%

RR 0.48

3.1

19.2

11.2

10.1

5.1

Study cohort

OR

4%

6.2

ns P= 0.02 P= 0.04 P= 0.02


Survival Rcc+mmv = 7.8% Survival Rcc only = 6.7%

42/604 (6.9%) 15/447 (3.3%)


Survival after resuscitation

Off-duty medical personnel

Survival Lay rescuers

•Only reporting on patients with a cardiac cause •Excluded age <18 yr;non-cardiac cause

Lay rescuers

Survival after resuscitation


Non-inferiority design II

Odds ratio 1.10 (0.86-1.40)

Overleving kan liggen tussen 5.2% en 8.3% absoluut verschil -2.6% en +0.5%

CC Only slechter

7.8%

CC Only beter overlevingskans

CC only

Wat is het maximum nadeel dat we willen accepteren? 0%? 0.5%? 1%?

11

30-3-2015



Main result: survival

Survival without and with Basic Life Support 80

CC and CC only ventilatio n 6%

4%

apnea

6.2

3.1

VF

19.2

11.2

Resuscitation < 4 min

10.1

5.1

ns P= 0.02 P= 0.04 P= 0.02


Conclusion on chest compression only CPR •Current guidelines 2005 (including C:V ratio 30:2) are adequate •Evidence from Lancet paper is insufficient to change guidelines •Re-evaluate science in ILCOR Guidelines process 2010

No BLS

Survival (%)

Overall

60

BLS

40

20

0 0

5

10 15 First defibrillation (min)

20

25


Change at ILCOR 2000: practice Compression rate 100/minute 2 respirations in 5 sec

Compressions/minute

Respirations/minute

5:1

55

11

15:2

65

8

Compression rate 100/minute 2 respirations in 16 sec*

Compressions /minute

Respirations/minute

5:1

28

5

15:2

45

4 *Assar Resuscitation 2000


Non-inferiority design I

• Therapie onderzoek: – Meestal “nieuw middel is beter dan oud middel” • Bewijs: significant beter b.v. nieuw tenminste 10% beter

– Soms “nieuw middel is gelijk aan oud middel” • Bewijs: nieuw niet significant slechter dan oud b.v. nieuw maximaal 10 % slechter


Observational cohort •Confounding •confounder: –Covariate, not related to variable of interest (cardiac only resuscitation) –Determinant of outcome (survival) –Unevenly distributed among groups

Off-duty medical personnel vs. lay rescuers

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30-3-2015

Waarom beademen belangrijk Survival afteris

Study (outcome) Nagao 2002-2003 (Japan) (30 days, good neurologic)

cardiac arrest

Waarom beademen belangrijk is Is Basic Life Support important?

“standard” = CC en MMV

CC only

RR (95% CI)

4%

6%

1.5 (0.9-2.5) 2006

Bohm 19902005(Sweden) (1 month, good neurologic)

7.2

Iwami 1998-2003 (Japan) (1 year, good neurologic)

3.6

3.5

0.97 (0.55-1.73)

Bobrow 2005-2007 (USA) (survival to discharge)

1.8

5.4

2.94 (1.06-8.16)

6.7

0.93 (0.74-1.17) 2003-2006

Waalewijn1995 (Holland) Berdowski 2006 (Holland) (hospital discharge)

2003 1998-2003

2005

9.7 16.9

Waarom beademen belangrijk is Four supportive studies




Respons from ERC

Type of CPR

2005

2006

2007

2008

2009

change

none

72%

67%

68%

64%

60%

-12%

conventional

23%

17%

17%

12%

10%

-13%

CC only

5%

15%

15%

23%

30%

+25%

Overall survival

3.7%

7.2%

6.7%

6.6%

9.8%

+6.1%


2,4%

5,5%

4,7%

4,2%

3,6%

+1.2%

•Only reporting on patients with a cardiac cause •Increase of CC only CPR half from less full CPR •Neuro intact survival minimal – role of TH? •Effectiveness study •Interventions in the real world •All patients in the community accounted for •Outcome neuro intact survival

13

30-3-2015



Relation of collapse to CPR and defibrillation to survival: simplified model.

Survival without and with Basic Life Support 80 No BLS BLS

Survival (%)

60

40

20

0 0

Valenzuela T D et al. Circulation. 1997;96:3308-3313

Copyright © American Heart Association, Inc. All rights reserved.


5

10 15 20 First defibrillation (min)

25

Waalewijn Resuscitation 2002


Survival without and with Basic Life Support

Is ventilation needed during –Circulatory arrest isCPR? not always primary cardiac

•Pro:

80 No BLS

arrest (drowning, ashyxia, children) –Oxygen content decreases rapidly during CPR –Carbon dioxide needs to be removed –Evidence from time of 5:1 C:V ratio

BLS

Survival (%)

60 40 20

•Con –Interruption of chest compression decreases CPP –Animal evidence suggests improved survival –Rescuers hate to do mouth-to-mouth breathing –Telephone CPR is better when only CC tought

0 0

5

10 15 20 25 First defibrillation (min)

Waalewijn Resuscitation 2001

Valenzuela Circulation 1997


Verschillende issues

Guidelines 2005: do C:V ratio 30:2 when acceptable

Waarom beademen belangrijk is Chest compressions not/minimally interrupted

• Pause/onderbrekingen – Pre-shock;post-shock;ventilaties

• Niet willen blazen

Kern Resuscitation 1998

14

30-3-2015



Type of CPR

2005

2006

2007

2008

2009

Type of CPR

2005

2006

2007

2008

2009

change

none

72%

67%

68%

64%

60%

change

none

72%

67%

68%

64%

60%

-12%

full

23%

17%

17%

12%

10%

full

23%

17%

17%

12%

10%

-13%

CC only

5%

15%

15%

23%

30%

CC only

5%

15%

15%

23%

30%

+25%



Type of CPR

2005

2006

2007

2008

2009

change

Type of CPR

2005

2006

2007

2008

2009

change

none

72%

67%

68%

64%

60%

-12%

none

72%

67%

68%

64%

60%

-12%

full

23%

17%

17%

12%

10%

-13%

full

23%

17%

17%

12%

10%

-13%

CC only

5%

15%

15%

23%

30%

+25%

CC only

5%

15%

15%

23%

30%

+25%

3.7%

7.2%

6.7%

6.6%

9.8%

+6.1%

Overall survival

3.7%

7.2%

6.7%

6.6%

9.8%

+6.1%


2,4%

5,5%

4,7%

4,2%

3,6%

+1.2%

Overall survival

•Only reporting on patients with a cardiac cause •Excluded age <18 yr;non-cardiac cause •Requirements for effectiveness study: •Interventions in the real world •All patients in the community accounted for •Meaningful outcome



Arrest 2: survival without and with Basic Life Support Waalewijn 1995-1997

Resuscitation 2007;73:229-235

80

60

Survival (%)

No BLS

BLS

40

20

0 0

5 10 15 First defibrillation (min)

20

25

15

30-3-2015



Survival without and with Basic Life Support

80

Conclusion 60

Survival (%)

No BLS BLS

40

Oxygen is needed many minutes before ambulance arrival Compression only CPR has not proven to be equal, and certainly not superior!

20

0 0

5

10 15 First defibrillation (min)

20

25



Studies 1995-2011

Ambulances are fast……

Author-year

Journal

OR (CI)

N=

Marwick 1995

Resuscitation

3.5 (2.0-6.1)

487

Hulik 1997

Resuscitation

2.9 (1.1-7.3)

251

Waalewijn 2001

Resuscitation

2,5 (1.6-4.0)

476

Herlitz 2005

Resuscitation

2.0 (1.7-2.4)

2076

Fridman 2007

Resuscitation

2.0 (1.3-3.3)

3009

Iwami 2007

Circulation

1.6 (0.95-2.6)

783

Hinchey 2010

Ann. Emerg. Med

9.9 (3.2-16.6)

Daisy 2011

Resuscitation

1.3 (1.0-1.7)

6360

Abrams 2011

Resuscitation

1.7 (1.0-3.0)

1156

But are they that fast?

2-3x better survival



Meursing JACC 1983: 6 dogs (abstract only)

And what about gasping? Compressions also move air

16

30-3-2015


Human evidence


Is survival really similar?


Early: ≤8 minutes

Waarom beademen belangrijk is Compression-only CPR vs. Full CPR (Bohm 2007)

Late: >8 minutes Electrical phase

Circulatory phase

Metabolic phase

Three-phase model

The model should follow the data



De wereld heeft eindelijk C-A-B geaccepteerd! 1983 2010

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18

Waarom beademen belangrijk is. 2-3x beter! Overleving Arrest Noord-Holland. Overleving in Europa

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