We reviewed airway and breathing management guidelines published in the BLS and ALS sections of the AHA resuscitation guidelines during the past 20 years (1992,23 2000,24–26 2005,27,28 and 201021,22) and compared the judgment of benefit of both BLS and ALS recommendations (e.g., tidal volume, respiratory rate, % FIO2) and the level of the evidence of the most recent recommendations.
In light of their role as specialists in airway management and resuscitation, anesthesiologists are extremely familiar with clinical resuscitation. To provide some perspective on whether anesthesiologists agree with the authors of the American College of Cardiology--ECC guidelines with respect to the evidence underlying the management of airway and breathing and the associated levels of recommendation, we performed a survey among attendees of the 2011 annual meeting of the American Society of Anesthesiologists. At a 90-minute pro–con session entitled “Should we be following ASA not AHA guidelines” delivered by 2 of the authors, attendees were issued an electronic response device and informed that their responses may be used for study purposes. All but a minority felt that AHA-ECC airway and breathing management guidelines were not up to par with anesthesia airway management guidelines (Table 3) and that anesthesia experts should be more involved in the writing of these guidelines.
The paucity of evidentiary support for guideline recommendations is not a new finding,29,30 nor are mismatches between the strength of evidence and level of recommendation.31–33 The goal of evidence-based medicine is to “track down the best external evidence with which to answer our clinical questions.”34 As shown above, the body of literature that informs the current incarnation of ALS recommendations falls short of this ideal because few ALS recommendations are based on evidence from the highest quality of research (Fig. 2). In light of these observations, ongoing revision of the original CPR guidelines using contemporary evidence-based approaches35 is a positive development. In guidelines that have existed for decades, change is expected and likely reflects better science.
Both animal studies and clinical trials during the past 15 years have produced fundamental changes in CPR. One recent example is the 2013 article by Hasegawa et al., which describes an increased likelihood of neurologically favorable survival of adult victims of cardiac arrest who received bag-valve-mask ventilation alone compared with those who underwent any type of advanced airway management.36 Such findings clearly require further assessment, which would benefit from involvement by experts in airway management. The exponential increase in the rate of clinical resuscitation research worldwide37 suggests that guidelines will likely continue to change as they become based on increasingly better evidence. However, as of now, changes are occurring with little anesthesia contribution or involvement.
The use of lipid emulsions for treatment of local anesthetic-induced cardiovascular collapse38–40 and the study of maternal arrest and resuscitation41–44 show that anesthesiologists can significantly contribute to resuscitation research. We should continue to contribute to future resuscitation guidelines with more well-performed clinical research in our areas of expertise. Alternative pressors (some of which are being used mainly by anesthesiologists), balanced drug use, early warning systems, monitoring (e.g., capnography and echocardiography for assessing return of spontaneous circulation), and differences between various types of cardiac arrest (e.g., respiratory, iatrogenic) are but a few such topics.
We should collaborate more with the community of researchers in resuscitation. Much of what is known today about airway management is either taken from expert opinion or inferred from observational studies or “randomized controlled trials without pertinent controls.”45 This paucity of controlled data is most glaring in the uncontrolled environment of CPR. We should use our expertise in airway management to identify causes of failures in airway management both in the hands of less experienced providers in general and in the hands of highly trained providers in austere settings. We should also share our experience in managing critical situations unique to the perioperative and inpatient settings, which remain unaddressed in current guidelines.
ILCOR is currently considering dynamic online guideline development using a “wiki” platform (methodologically similar to the development and maintenance of Wikipedia). Regardless of the platform to be used, anesthesiologists should become more involved in the development of resuscitation guidelines. Resuscitation is a multidisciplinary effort and can only benefit from the participation of anesthesiologists. We anesthesiologists have proved that we can change patient outcomes for the better. What better place to expand this contribution than in the area of medicine in which patients have the grimmest outcomes of all?
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