Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (David Szpliman)
Task Force Scoping Review Citation
Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, Scapigliati A, Seesink J, Schmidt A, Sempsrott J, Szpliman D, Warner DS, Webber J, Johnson S, Avis S, Mancini MB, Nation K, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Nishiyama C, Ristagno G, Semeraro F, Smyth M, Vaillancourt C, Olasveengen T, Morley P, Perkins GD on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force(s).
Airway Management in drowning. Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 7 July 2020. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of the literatures undertaken by Jonathon Webber and Patrick Morgan and co-ordinated by Gavin Perkins and Joost Bierens. The findings from the review of basic life support were considered by the Basic Life Support Task Force who contributed to the Task Force insights.
Scoping Review
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: advanced airway management
Comparators: no advanced airway management
Outcomes: Any clinical outcome (e.g. survival, survival with a favourable neurological outcome, hospitalization), CPR quality, physiological end-points
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Manikin studies will only be included if no human studies are available.
Timeframe: From 2000 onwards. All languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols), narrative reviews, animal studies were excluded. Literature search updated to October 2019.
Search Strategies
BLS-856-Drowning-CPR-Search-Strategies
Inclusion and Exclusion criteria
Inclusion criteria:
- Adult and paediatric patients
- Submersion in water (drowning, near drowning)
- Describe advanced airway management approaches
- Studies report clinical outcomes e.g. survival, survival with a favourable neurological outcome, hospitalisation
- Other outcomes: CPR quality, physiology
Exclusion criteria:
- Animal studies
- Results reported in the gray literature or abstract only
- Narrative reviews containing no primary data
- Published as an abstract only or in conference proceedings.
- Case studies / series without control groups, unless no or minimal other literature available.
Data tables
Task Force Insights
1. Why this topic was reviewed.
Drowning is the third leading cause of unintentional injury death worldwide, accounting for over 360 000 deaths annually.[World Health Organization, 2020] Submersion in water leads to the rapid onset of hypoxia. Left untreated cardiac arrest occurs within minutes. Airway management is pivotal to effective resuscitation, but the optimal strategy is unclear. The BLS Task Force and Drowning collaboration considered it timely to undertake a scoping review of the literature to identify any new evidence related to this topic.
2. Narrative summary of evidence identified
The literature search identified 3005 articles (2190 after removal of duplicates). After screening titles and abstracts, 52 studies were identified for full text review.
No studies specifically examined the effect of a particular airway management strategy over another, or no intervention, in the management of a submerged casualty.
Five observational studies indirectly examined airway management strategies in 699 adults and children following drowning events.[Garner, 2015, 92; Joanknecht, 2015, 123; Kieboom, 2015, h418; Hubert, 2016, 924; Salas Ballestin, 2018, 16] One study reported outcomes in adults and children[Hubert, 2016, 924] whilst the other four studies reported only paediatric cases.[Garner, 2015, 92; Joanknecht, 2015, 123; Kieboom, 2015, h418; Salas Ballestin, 2018, 16] Some studies reported only those who sustained cardiac arrest due to drowning.[Kieboom, 2015, h418; Hubert, 2016, 924]
All studies reported survival: specifically survival with good neurological outcome,[Garner, 2015, 92] survival to hospital admission,[Hubert, 2016, 924] good outcome v bad outcome (death or neurological sequelae),[Joanknecht, 2015, 123] and good outcome versus poor outcome (death or severe encephalopathy).[Salas Ballestin, 2018, 16]
In all studies intubation was an indication of the severity of the injury, with the most severely injured being intubated during cardiac arrest or facilitated with anaesthesia, without comprehensive adjustment for confounders. Two studies showed intubation was associated with worse outcome (OR good outcome 0.25 (0.08 to 0.83),[Kieboom, 2015, h418] OR 0.04 (0.01 to 0.2),[Joanknecht, 2015, 123] One study showed mobile medical team ventilation as associated with better outcomes (44% versus 17% survival to admission).[Garner, 2015, 92]
3. Narrative Reporting of the task force discussions
The limited evidence base identified in the scoping review, suggests little benefit A limited evidence base was identified in this scoping review, but a systematic review on this topic will be required if a recommendation is intended to be made by the task force.
The studies reviewed show that that intubation is a feasible intervention following a submersion incident. The association between intubation and poor outcomes is almost certainly confounded by the need for intubation being an intervention limited to more severe drowning.
In the absence of data supporting an alternative strategy, there is no reason to deviate from the ALS Task Force recommendations for airway management.[ILCOR CoSTR 2020 ALS]
Knowledge Gaps
Current knowledge gaps include but are not limited to:
Feasibility and effectiveness of different airway management strategies in different settings (e.g. in-water, scene, emergency department)
Prospective observational studies and randomised trials reporting clinical outcomes of different airway management strategies in drowning.
Studies in low resource settings were lacking.
References
References listed alphabetically by first author last name in this citation format
Garner, A. A., et al. (2015). "Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service." Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine 23: 92.
Hubert, H., et al. (2016). "Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry." Journal of Evaluation in Clinical Practice 22(6): 924.
Joanknecht, L., et al. (2015). "Childhood drowning in South Africa: local data should inform prevention strategies." Pediatric Surgery International 31(2): 123.
Kieboom, J. K., et al. (2015). "Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study." BMJ 350: h418.
Salas Ballestin, A., et al. (2018). "Prognostic Factors of Children Admitted to a Pediatric Intensive Care Unit After an Episode of Drowning." Pediatric Emergency Care 16: 16.
World Health Organization (2020) Drowning.