Long-term prognosis and clinical course after choking-induced cardiac arrest: A population- based community study from the Shizuoka Kokuho Database

doi:10.21203/rs.3.rs-1403259/v1

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Research Article

Long-term prognosis and clinical course after choking-induced cardiac arrest: A population- based community study from the Shizuoka Kokuho Database

https://doi.org/10.21203/rs.3.rs-1403259/v1

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Background : Choking is increasing with aging, and cases of choking-induced cardiac arrest are increasing. However, few studies have examined the prognosis of choking-induced cardiac arrest. The aim of this study was to reveal the long-term prognosis of choking-induced cardiac arrest after resuscitation.

Methods : W We used the Shizuoka Kokuho Database. This database consists of claim data of approximately 2.2 million people during April 2012 to September 2018. From the database, we selected patients with choking-induced cardiac arrest who received cardiopulmonary resuscitation in the hospital.. Patients were excluded if they were under 20 years old, had an upper airway tumor, were on ventilator control, were fed enteral nutrition in the month prior to cardiac arrest. The primary outcome was death, and secondary outcomes were the 3-month survival rate, independence on devices. Descriptive statistics are presented and compared across age groups (20-64 years, 65-74 years, 75-84 years, 85 years and older), and survival time analysis (Kaplan-Meier method) was performed.

Results : A total of 268 patients were analyzed: 26 patients in the 20-64 age group, 33 patients in the 65-74 age group, 70 patients in the 75-84 age group, and 139 patients in the ≥85 age group. The 3-month survival rate was 5.6% (15/268). For each group, it was 3.8% (1/26) in the 20-64 age group; 15.2% (5/33) in the 65-74 age group; 8.6% (6/70) in the 75-84 age group; and 2.2% (3/139) in the ≥85 age group. The 12-month survival rate was 2.6% (7/268). Of the 7 patients who survived 12 months, 3 were on ventilator management and 5 were on tube and intravenous feedings at 3 months. These survivors were still on ventilators and tube feedings in the hospital and had not been discharged at 12 months.

Conclusions : The prognosis of choking-induced cardiac arrest was extremely poor when patients were not resuscitated before arrival at the hospital. Even if they survived, they were mostly dependent on assistive devices. In addition, none of the survivors dependent on assistive devices had discontinued the use of the devices even at long-term follow-up.

choking

cardiac arrest

resuscitation

long-term prognosis

clinical course

Choking is an emergency condition that can lead to death if the choking object is not removed early. It has been shown that the number of deaths from asphyxia due to choking increases with age in the elderly[1–6]. In Japan, where aging is advancing at the fastest pace in the world, there are approximately 9,000 deaths due to choking annually, making it the second most common cause of accidental death[6]. Considering the aging of the population, especially in developed countries, it is expected that choking-induced cardiac arrest will become a major problem in the future[1–6].

Little research has been done on the prognosis after the return of spontaneous circulation. According to a few previous studies, the 30-day survival rate was reported to be approximately 14%[7, 8], and only 5% of patients who were discharged had a good neurological prognosis (cerebral performance categories (CPCs):1–2) at the time of discharge[8, 9]. However, previous studies only evaluated the short-term prognosis and did not assess the long-term prognosis.

Furthermore, it is expected that some discharged patients will be device-dependent and will confer financial and mental burdens on their families or partners[10, 11]. Therefore, research on the status of discontinuation from assistive devices after discharge can provide a basis for families and physicians in deciding on a treatment plan. In addition, another study reported that regarding the long-term prognosis of patients after cardiopulmonary resuscitation, "cognitive function" and "activities of daily living (ADL)" improved up to 12 months after resuscitation[12, 13]. Therefore, long-term follow-up of patients with choking-induced cardiac arrest to see if their living conditions improve will help us decide on whether to aggressively intervene in the treatment of choking-induced cardiac arrest.

In this study, we evaluated the “long-term prognosis” and “clinical courses after resuscitation” of choking-induced cardiac arrest and showed the dependence of survivors on assistive devices after resuscitation to reveal their living conditions.

Database

We used the Shizuoka Kokuho Database for this study. This database consists of administrative claims database from Shizuoka Prefecture, Japan. Shizuoka Prefecture has a population of approximately 3.6 million as of 2020.

There are three main types of health insurance in Japan: the Employee’s Health Insurance (EHI), the National Health Insurance (NHI) and Late Elder’s Health Insurance (LEHI); the EHI and NHI are for those under the age of 75. The NHI is designed for people who are mainly self-employed citizens, part-time workers, and unemployed people. Employees of large or small companies are not enrolled in the NHI. All individuals over the age of 75 are enrolled in the LEHI. The Shizuoka Kokuho Database consists of the NHI and LEHI and represents approximately 2.2 million people in Shizuoka Prefecture[14].

In this study, we used the database from April 2012 to September 2018. This database consists of the registrant information (which included age, sex, observation period, reason for withdrawal, and death dates), the insurance claim data (which included data on prescribed medicines, procedures, and the 10th Revision of the International Classification of Diseases (ICD-10)), and the long-term care insurance data (which included support and care level as well as information about care services provided for insured individuals). All prescribed medicines are coded in Japanese original codes, and each code is linked to an Anatomical Therapeutic Chemical Classification System (ATC) code. These data were tied to individuals by anonymized individual identifiers for research purposes.

The study was approved by the institutional review board of Shizuoka General Hospital (Shizuoka, Japan; SGHIRB#2020021), and informed consent was waived because of the anonymous nature of the data.

Study population

We included patients who had suffered choking-induced cardiac arrest and were transferred to the hospital from April 2012 to September 2018. We selected those who had undergone nonopen chest compressions and were given a diagnosis of "choking” (ICD-10: T172, T173, T174, T175, T178, T179, T71) in the same month. We excluded those who were under 20 years old, had an upper airway tumor, were on ventilator control, or were fed enteral nutrition in the month prior to cardiac arrest. In addition, we excluded those who lacked claim data during 6 months before the event.

Outcomes

The primary outcome was death. In this database, the recordings of deaths were counted separately with insurance withdrawal. As a secondary outcome, we assessed the 3-month survival rate, independence on ventilators, and independence on tube feeding or total parenteral nutrition (TPN).

Patient characteristics and clinical course

Other variables included age, sex, comorbidities (dementia, stroke, Sjogren's syndrome), medications (antipsychotics, dopamine agonists, sedative agents, anticholinergic agents), and living conditions before the event (ADL, nursing home, history of aspiration pneumonia, dysphagia rehabilitation). In addition, we tabulated the presence of targeted temperature management, tracheostomy, gastrostomy, and dysphagia rehabilitation as procedures after choking-induced cardiac arrest. We identified stroke, Sjogren’s syndrome, and aspiration pneumonia from the ICD-10. We identified dementia, antipsychotics, dopamine agonists, sedative agents, and anticholinergic agents from Japan's own pharmaceutical codes linked to ATC codes. In Japan, the level of care needs is categorized into seven levels: two levels of support that are relatively independent and five levels of care needs that are dependent on nursing care.[15, 16] We defined independence in ADLs as care needs level 2 or less and dependence as care needs level 3 or more. Whether or not the person was in a nursing home were extracted from the care insurance data. The data for dysphagia rehabilitation, targeted temperature management, tracheostomy, and gastrostomy were extracted from the medical insurance data.

Statistics

We summarized the data as the mean and standard deviation (SD) or median and interquartile range (IQR) for continuous variables and frequency and percentage for categorical variables.

Kaplan-Meier survival analysis was used to assess long-term survival time. Survival time was compared across age groups (20–64 years, 65–74 years, 75–84 years, 85 years and older). It was also compared between the ventilator- and nonventilator-dependent groups at 3 months.

Statistical analyses were undertaken using Stata (version: 16.1; StataCorp, 2020, College Station) and R (version: 4.0.1; R Foundation for Statistical Computing), and a two-sided significance level < 0.05 was considered statistically significant.

From the Shizuoka Kokuho Database from April 2012 to September 2018, 21,300 cardiac arrests were extracted. Of these cases, 268 patients were included in the final analysis (Fig. 1).

Age group

Characteristics of the patients who had choking-induced cardiac arrest by age group are shown in Table 1. More than half of the individuals experiencing choking-induced cardiac arrest were over 85 years old. The number of patients taking antipsychotics and sedative agents tended to be higher in the younger age group. Especially in the 20–64 age group, 57.7% were taking antipsychotics, and 50.0% were taking anxiolytics. The proportion of patients taking dopamine agonists was higher in the 75–84 age group than in the ≥ 85 age group (≥ 85 age group: 7.2%, 75–84 age group: 18.6%), and the proportion of patients with stroke was also higher in the 75–84 age group than in the ≥ 85 age group (≥ 85 age group: 31.7%, 75–84 age group: 40.0%). Overall, the percentage of patients with Sjogren's syndrome was 1.9%. The percentage of those who had dysphagia rehabilitation within 12 months before choking-induced cardiac arrest tended to increase with age (20–64 age group: 3.8%, 65–74 age group: 0%, 75–84 age group: 5.7%, ≥ 85 age group: 6.5%). The proportion of patients with a history of aspiration pneumonia within 12 months before choking-induced cardiac arrest tended to increase with age (20–64 age group: 3.8%, 65–74 age group: 3.0%, 75–84 age group: 7.1%, ≥ 85 age group: 10.1%).

Table 1

Characteristics of choking-induced cardiac arrest by age group
	Total	20–64 years old	65–74 years old	75–84 years old	≥ 85 years old
	N = 268	N = 26	N = 33	N = 70	N = 139
Age, median(IQR)	85 (79–89)	56.5 (51–62)	70 (67–72)	82 (80–83)	89 (87–92)
Men, n(%)	144 (53.7%)	16 (61.5%)	17 (51.5%)	47 (67.1%)	64 (46.0%)
Antipsychotic, n(%)	62 (23.1%)	15 (57.7%)	15 (45.5%)	14 (20.0%)	18 (12.9%)
Dopamine agonists, n(%)	25 (9.3%)	0 (0.0%)	2 (6.1%)	13 (18.6%)	10 (7.2%)
Anticholinergic agents, n(%)	42 (15.7%)	8 (30.8%)	7 (21.2%)	15 (21.4%)	12 (8.6%)
Sedative agents, n(%)	80 (29.9%)	13 (50.0%)	14 (42.4%)	14 (20.0%)	39 (28.1%)
Steroid, n(%)	13 (4.9%)	0 (0.0%)	1 (3.0%)	5 (7.1%)	7 (5.0%)
Dementia(with donepezil), n(%)	38 (14.2%)	0 (0.0%)	3 (9.1%)	11 (15.7%)	24 (17.3%)
Stroke, n(%)	81 (30.2%)	1 (3.8%)	8 (24.2%)	28 (40.0%)	44 (31.7%)
Sjogren's syndrome, n(%)	5 (1.9%)	0 (0.0%)	2 (6.1%)	3 (4.3%)	0 (0.0%)
Daily life independence level, n(%)
Unrated	99 (36.9%)	25 (96.2%)	17 (51.5%)	26 (37.1%)	31 (22.3%)
Independence	64 (23.9%)	0 (0.0%)	9 (27.3%)	19 (27.1%)	36 (25.9%)
Dependence	105 (39.2%)	1 (3.8%)	7 (21.2%)	25 (35.7%)	72 (51.8%)
Nursing home, n(%)	15 (5.6%)	0 (0.0%)	1 (3.0%)	4 (5.7%)	10 (7.2%)
State of dysphagia(within 12 months)
Dysphagia rehabilitation, n(%)	14 (5.2%)	1 (3.8%)	0 (0.0%)	4 (5.7%)	9 (6.5%)
Aspiration pneumonia, n(%)	21 (7.8%)	1 (3.8%)	1 (3.0%)	5 (7.1%)	14 (10.1%)
Procedure after cardiac arrest
TTM, n(%)	1 (0.4%)	0 (0.0%)	0 (0.0%)	1 (1.4%)	0 (0.0%)
Tracheostomy, n(%)	13 (4.9%)	1 (3.8%)	6 (18.2%)	3 (4.3%)	3 (2.2%)
Gastrostomy, n(%)	1 (0.4%)	0 (0.0%)	0 (0.0%)	1 (1.4%)	0 (0.0%)
Dysphagia rehabilitation, n(%)	8 (3.0%)	0 (0.0%)	1 (3.0%)	3 (4.3%)	4 (2.9%)
Survival after CA, n(%)
1 month following CA, n(%)	36 (13.4%)	2 (7.7%)	9 (27.3%)	9 (12.9%)	16 (11.5%)
3 months following CA, n(%)	15 (5.6%)	1 (3.8%)	5 (15.2%)	6 (8.6%)	3 (2.2%)
12 months following CA, n(%)	7 (2.6%)	0 (0.0%)	3 (9.1%)	3 (4.3%)	1 (0.7%)
Abbreviations: IQR, interquartile range; TTM, targeted temperature management; CA, cardiac arrest

The overall 3-month survival rate was 5.9%, and the 12-month survival rate was 2.6%. Figure 2 shows the survival curves of each age group. In all age groups, more than 80% of patients died within 3 months after choking-induced cardiac arrest, and less than 10% of them survived for 12 months. All the patients had died by 38 months.

Of the 7 twelve-month survivors, 3 were on ventilators, and 5 were on tube feedings or TPN at 3 months. These survivors were still on ventilators and tube feedings or TPN in the hospital and had not been discharged at 12 months. Only one patient (0.37%; 1/268) survived for 12 months and returned home without any assistive devices.

We plotted the number of incidences of choking-induced cardiac arrest per month (Fig. 3). The number of incidents in Japan is concentrated in winter, especially from November to March.

Survivor group and nonsurvivor group at 3 months after cardiac arrest

The characteristics of survivors and nonsurvivors at 3 months after cardiac arrest are shown in Table 2. The survivors were younger in age. All those who had dysphagia rehabilitation within 12 months died. Twenty of 21 patients who had aspiration pneumonia within 12 months died within 3 months. Approximately half of the surviving patients had a tracheostomy (53.3%).

Table 2

Comparison between nonsurvivors and survivors at 3 months after cardiac arrest
	Total	Nonsurvivor	Survivor
	N = 268	N = 253	N = 15
Age, median(IQR)	85 (79–89)	85 (80–89)	78 (68–84)
Men, n(%)	144 (53.7%)	136 (53.8%)	8 (53.3%)
Antipsychotic, n(%)	62 (23.1%)	55 (21.7%)	7 (46.7%)
Dopamine agonists, n(%)	25 (9.3%)	22 (8.7%)	3 (20.0%)
Anticholinergic agents, n(%)	42 (15.7%)	37 (14.6%)	5 (33.3%)
Sedative agents, n(%)	80 (29.9%)	75 (29.6%)	5 (33.3%)
Steroid, n(%)	13 (4.9%)	12 (4.7%)	1 (6.7%)
Dementia(with donepezil), n(%)	38 (14.2%)	36 (14.2%)	2 (13.3%)
Stroke, n(%)	81 (30.2%)	76 (30.0%)	5 (33.3%)
Sjogren's syndrome, n(%)	5 (1.9%)	5 (2.0%)	0 (0.0%)
Daily life independence level, n(%)
Unrated	99 (36.9%)	93 (36.8%)	6 (40.0%)
Independence	64 (23.9%)	60 (23.7%)	4 (26.7%)
Dependence	105 (39.2%)	100 (39.5%)	5 (33.3%)
Nursing home, n(%)	15 (5.6%)	15 (5.9%)	0 (0.0%)
State of dysphagia(within 12 months)
Dysphagia rehabilitation, n(%)	14 (5.2%)	14 (5.5%)	0 (0.0%)
Aspiration pneumonia, n(%)	21 (7.8%)	20 (7.9%)	1 (6.7%)
Abbreviations: IQR, interquartile range

The ventilator-dependent group and the nonventilator-dependent group at 3 months after cardiac arrest

A comparison between the ventilator-dependent group and the nonventilator-dependent group at 3 months after cardiac arrest is shown in Table 3. Of the 15 three-month survivors, 6 were on ventilators, 9 were on tube feedings, and 4 were on central venous feedings. In the ventilator-dependent group, tracheostomy was performed in 83% (5/6), and in the nonventilator-dependent group, tracheostomy was performed in 33% (3/9). In the ventilator-dependent group, no one received dysphagia rehabilitation, whereas in the nonventilator-dependent group, 22% (2/9) received dysphagia rehabilitation. In the ventilator-dependent group, the survival time including the initial 3 month assessment period was 8.0 months (IQR: 7.0–17.0 months), compared with 29.0 months (IQR: 5.0–38.0 months) in the nonventilator-dependent group. Figure 4 shows the survival curves of each group.

Table 3

Comparison between ventilator-dependent and nonventilator-dependent patients at 3 months
	Total	Nonventilator dependent	Ventilator dependent
	N = 15	N = 9	N = 6
Age, median(IQR)	78 (68–84)	78 (70–81)	76 (66–86)
Men, n(%)	8 (53%)	5 (56%)	3 (50%)
TTM, n(%)	1 (7%)	1 (11%)	0 (0%)
Tracheostomy, n(%)	8 (53%)	3 (33%)	5 (83%)
Gastrostomy, n(%)	1 (7%)	1 (11%)	0 (0%)
Dysphagia rehabilitation, n(%)	2 (13%)	2 (22%)	0 (0%)
Tube feeding at 3 months, n(%)	9 (60%)	4 (44%)	5 (83%)
CVC at 3 months, n(%)	4 (27%)	1 (11%)	3 (50%)
Survival in the 12 months, n(%)	7 (47%)	4 (44%)	3 (50%)
Survival month, median(IQR)	17 (5–29)	29 (5–38)	8 (7–17)
Abbreviations: IQR, interquartile range; TTM, targeted temperature management; CVC, central venous catheter

In the present study, we revealed that the prognosis of choking-induced cardiac arrest was extremely poor when patients were not resuscitated before arrival at the hospital. Even if they achieved the return of spontaneous circulation and survived, they were mostly dependent on assistive devices. In addition, none of the survivors dependent on assistive devices had discontinued the use of the devices even at long-term follow-up. Twelve months after choking-induced cardiac arrest, only one of 268 patients returned home without any assistive devices. To our knowledge, this is the first study that showed the long-term prognosis and detailed clinical course after choking-induced cardiac arrest.

Previous studies have shown that cardiac arrest due to hypoxia is more damaging to brain neurons than cardiogenic cardiac arrest.[17] The present result of extremely poor prognosis is consistent with the results of previous studies and is clinically convincing. Therefore, cardiac arrest due to hypoxia needs to be distinguished from cardiogenic cardiac arrest. Another previous study showed that cognitive function and activities of daily living of resuscitated cardiac arrest patients improved by 12 months after resuscitation[12, 13], and these results are not consistent with ours. We believe that there are two reasons for this. One is that the subjects in the previous study included cardiogenic cardiac arrest, and the other is that the subjects analyzed in our current study were choking-induced cardiac arrest with a relatively poor prognosis because they did not achieve the return of spontaneous circulation until hospital arrival.

Therefore, when resuscitation is not achieved before arrival at the hospital, the prognosis of choking-induced cardiac arrest is extremely poor, the poor state is fixed in a relatively short period of time, and the possibility of improvement thereafter is extremely low. In addition, aggressive therapeutic interventions such as cardiopulmonary resuscitation at the hospital (intubation, intravenous fluids, chest compressions, electrical defibrillation, etc.) for choking-induced cardiac arrest may have little response. These findings suggest that failure to return of spontaneous circulation before arrival at the hospital is in itself a strong prognostic factor for a poor outcome. This can provide the basis for deciding whether to continue aggressive therapeutic intervention for choking-induced cardiac arrest.

It is generally understood that early removal of choking objects in choking-induced cardiac arrest contributes significantly to the return of spontaneous circulation and improvement of prognosis[8, 18]. This study deals uniformly with choking-induced cardiac arrest in Shizuoka Prefecture, but there are differences in medical access within the region. Some areas had good access to medical care, but the fact that 1/268 of the patients were discharged home after choking-induced cardiac arrest is too poor a prognosis. Considering this result, it may be suggested that to improve the prognosis of choking-induced cardiac arrest, we have to remove choking objects and resuscitate before arrival at the hospital. In the future, it is necessary to research prehospital asphyxia interventions (Heimlich maneuver, intubation, etc.) and their impact on prognosis.

Furthermore, this study clarified that age, psychiatric disorders, Parkinson's symptoms, Sjogren's syndrome, and seasonality were the factors that may influence the occurrence of choking. If families and caregivers know these factors beforehand, they can prevent choking and provide prompt assistance when choking occurs. In this study, 1.9% of patients with choking-induced cardiac arrest was diagnosed with Sjogren's syndrome. However, the incidence of Sjogren's syndrome has been reported to be 0.05 to 0.1%[19, 20], and the incidence in this study appears to be higher than these. Therefore, Sjogren's syndrome may influence the occurrence of choking-induced cardiac arrest. In Sjogren's syndrome, decreased saliva secretion may cause dysphagia, leading to choking. Regarding seasonality, the incidence of choking-induced cardiac arrest in Japan tended to be higher in winter (November to March). This is a major characteristic of Japan and is not found in Western countries[1]. Choking is influenced by dietary culture and habits, and choking objects differ from region to region[2, 21]. According to previous studies, the high incidence of choking in winter in Japan may be due to the influence of rice cakes[6, 22]. If the increase in choking-induced cardiac arrest from November to March is considered preventable, 1/3 of the annual number of cases can be prevented.

The strength of this study is that we were able to follow patients for a long period of time. Specifically, we were able to follow up for up to 38 months. Furthermore, since we used claim data, we were able to follow the dependence on assistive devices over a long period of time. Previous studies on choking-induced cardiac arrest have only reported one-month survival rates and survival discharge rates, but in this study, we found that even those who survived long-term after choking-induced cardiac arrest were mostly dependent on assistive devices. Essentially, in deciding on a treatment plan, the survival rate as well as the living conditions after discharge from the hospital should be taken into consideration. In this study, we were able to show the survival curve and the degree of dependence on devices of long-term survivors. This information is meaningful for the patients' families and doctors.

Limitation

The present study has some limitations. First, we could not assess some detailed clinical information. Information about the patient's address and the medical institution to which the patient was transported was not available. The Shizuoka Kokuho Database does not have information about the time, place, and caregiver at the onset of choking-induced cardiac arrest. Second, choking-induced cardiac arrest without resuscitation at the hospital was not included in this analysis. The prognosis of those who achieved the return of spontaneous circulation before hospital transport could be better, and it might be difficult to compare this result with other results of choking-induced cardiac arrest. Third, insured persons in the National Health Insurance Database may be different from the general population. The population in the Shizuoka Kokuho Database is expected to be old and frail, so we may have underestimated the prognosis of choking-induced cardiac arrest.

The prognosis of choking-induced cardiac arrest was extremely poor when patients were not resuscitated before arrival at the hospital. Even if they survived, they were mostly dependent on assistive devices. In addition, none of the survivors dependent on assistive devices discontinued the use of the devices even after long-term follow-up.

CPCs

cerebral performance categories

ADL

activities of daily living

NHI

the National Health Insurance

LEHI

the Late Elder’s Health Insurance

EHI

the Employee’s Health Insurance

ICD-10

the 10th Revision of the International Classification of Diseases

ATC

Anatomical Therapeutic Chemical Classification System

TPN

total parenteral nutrition

standard deviation

IQR

interquartile range

TTM

targeted temperature management

cardiac arrest

CVC

central venous catheter

Acknowledgments

The Research Support Center in Shizuoka General Hospital conducts contract research projects for public health in Shizuoka Prefecture, including this study.

Funding

This work was supported by the Research Support Center in Shizuoka General Hospital.

Author information

Affiliations

Shizuoka Graduate University of Public Health, Shizuoka, 4-27-2 Kita Ando Aoi-ku, Shizuoka City, 420-0881, Japan

Takahiro Miyoshi, Hiroyuki Yamamoto, Hiraku Kumamaru, Nao Ichihara, Yoshiki Miyachi, Hiroaki Miyata

Department of Health Policy and Management, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan

Takahiro Miyoshi, Hideki Endo, Hiroyuki Yamamoto, Koki Shimada, Hiroaki Miyata

Department of Healthcare Quality Assessment, The University of Tokyo Graduate School of Medicine, Tokyo, Japan

Hideki Endo, Hiraku Kumamaru, Nao Ichihara, Hiroaki Miyata

Contributions

T.M.: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing - original draft, Writing - review & editing. H.E.: Conceptualization, Methodology, Project administration, Writing- Original draft, Writing - review & editing. H.Y.: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Visualization, Writing- Original draft, Writing - review & editing. K.S.: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing - review & editing. H.K.: Data curation, Writing - review & editing. N.I.: Data curation, Writing- Reviewing and Editing. Y.M.: Project administration, Writing- Reviewing and Editing. H.M.: Data curation, Project administration , Writing- Reviewing and Editing.

Availability of data and materials

The data that support the findings of this study are available from the Research Support Center in Shizuoka General Hospital but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the corresponding authors upon reasonable request and with permission of the Research Support Center in Shizuoka General Hospital.

Ethics approval and consent to participate

The protocols of this study were examined and approved by the institutional review board of Shizuoka General Hospital (Shizuoka, Japan, SGHIRB#2020021). All methods were carried out in accordance with the relevant guidelines and regulations. Given the nature of the study (observational study routinely collected claim data), a formal waiver of individual consent and an approval of the study protocols were granted by the institutional review board of Shizuoka General Hospital.

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Competing interest reported. Dr. Yamamoto has received consultation fees from Mitsubishi Tanabe Pharma, speaker fees from Chugai Pharmaceutical Co., Ltd. and Ono Pharmaceutical Co., Ltd., and payment for a manuscript from Astellas Pharma Inc. Dr. Kumamaru has received consultation fees from Mitsubishi Tanabe Pharma and speaker fees from Pfizer Japan Inc. and Johnson & Johnson K.K. Dr. Miyata has received a research grant from AstraZeneca K.K. for an independent research project through the PeoPLe Consortium at Keio University. Drs. Endo, Yamamoto, Kumamaru, Ichihara, and Miyata are affiliated with the Department of Healthcare Quality Assessment at The University of Tokyo. This department is a social collaboration department supported by the National Clinical Database, Johnson & Johnson K.K., and Nipro Corporation. The other authors report no conflicts of interest directly relevant to the content of this article.

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Long-term prognosis and clinical course after choking-induced cardiac arrest: A population- based community study from the Shizuoka Kokuho Database

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Outcomes

Patient characteristics and clinical course

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Survivor group and nonsurvivor group at 3 months after cardiac arrest

The ventilator-dependent group and the nonventilator-dependent group at 3 months after cardiac arrest

Discussion

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