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: None
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).
Mechanical ventilation 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 David Szpliman and Joao Claudio Campos Pereira 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.
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: mechanical ventilation
Comparators: no mechanical ventilation
Outcomes: Any clinical outcome (e.g. survival, survival with a favourable neurological outcome, hospitilisation), 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.
Inclusion and Exclusion criteria
- Adult and paediatric patients
- Submersion in water (drowning, near drowning)
- Describe ventilation strategies
- Studies report clinical outcomes e.g. survival, survival with a favourable neurological outcome, hospitalisation
- Other outcomes: CPR quality, physiology
- 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.
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 leads to the rapid onset of hypoxia. The more severely injured lung may require support from a mechanical ventilator. The optimal ventilation strategy following submersion 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
Four studies were identified which examined the use of ventilation strategies in 93 adults/children following drowning.[Onarheim, 2004, 778; Caglar, 2016, 42; Ruggeri, 2016, 90; Michelet, 2017, 295] The studies comprised of 1 retrospective observational study with 88 patients, [Michelet, 2017, 295] 1 case series comprising 3 children,[Caglar, 2016, 42] and 2 case reports.[Onarheim, 2004, 778; Ruggeri, 2016, 90]
All papers reported discharge survival status at hospital discharge. Two papers reported neurological outcome (Glasgow coma scale) and severity of oxygen impairment.[Onarheim, 2004, 778; Michelet, 2017, 295]
Three studies reported the feasibility of NIV use in patients with respiratory failure after drowning.[Onarheim, 2004, 778; Caglar, 2016, 42; Michelet, 2017, 295]
In a multicentre, retrospective observational study, across 7 French ICUs, 48 adult patients received non-invasive ventilation (NIV, both CPAP and BiPAP, average PEEP 8 ±2 cmH2O) to treat moderate to severe lung injury (mean PaO2:FiO2 ratio 156 mmg Hg).[Michelet, 2017, 295] Compared to patients administered invasive mechanical ventilation, those receiving NIV had a better initial neurological (GCS 7 ±4 vs. 12 ± 3, P<0.05) and hemodynamic status (MAP 77 ± 18 vs. 96±18, P<0.001). NIV was successful in 92% (44/48) with an average duration of ventilation of 1.4 days (standard deviation 0.7d). Both MV and NIV were associated with rapid improvement of oxygenation (within 6 hours) and short ICU length of stay [3 (1–14) and 2 (1–7). Two further papers reported successful use of NIV to treat drowning related acute lung injury in haemodynamically stable adult[Onarheim, 2004, 778; Ruggeri, 2016, 90] and 3 children.[Caglar, 2016, 42] In each case the GCS was > 12, pressure support 10-18cm H2O and PEEP 5-8cm H2O.
3. Narrative Reporting of the task force discussions
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.
NIV appears feasible as a treatment for moderate to severe lung injury caused by drowning. The published experience involves mostly patients with higher GCS, who are haemodynamically stable. Patients appear to respond within 12-24 hours. The indications for the optimal time to transition to invasive ventilation if NIV is unsuccessful requires further research.
Evidence based strategies for the management of acute respiratory distress syndrome have been published.[Griffiths, 2019, e000420]
Current knowledge gaps include but are not limited to:
Prospective observational studies and randomised trials reporting clinical outcomes of non-invasive ventilation strategies following drowning.
Studies in low resource settings were lacking.
Caglar, A., et al. (2016). "Efficacy of early noninvasive ventilation in three cases of nonfatal drowning with pulmonary oedema in the paediatric emergency department." Hong Kong Journal of Emergency Medicine 23(2): 42.
Griffiths, M. J. D., et al. (2019). "Guidelines on the management of acute respiratory distress syndrome." BMJ Open Respir Res 6(1): e000420.
Michelet, P., et al. (2017). "Acute respiratory failure after drowning: a retrospective multicenter survey." European Journal of Emergency Medicine 24(4): 295.
Onarheim, H. and V. Vik (2004). "Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old." Acta Anaesthesiologica Scandinavica 48(6): 778.
Ruggeri, P., et al. (2016). "Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient." Respiratory Medicine Case Reports 17: 90.
World Health Organization (2020) Drowning.