Does Pre-hospital Endotracheal Intubation Improve Survival in Adults with Non-traumatic Out-of-hospital Cardiac Arrest? A Systematic Review

Abstract

IntroductionEndotracheal intubation (ETI) is currently considered superior to supraglottic airway devices (SGA) for survival and other outcomes among adults with non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if the research supports this conclusion by conducting a systematic review.MethodsWe searched the MEDLINE, Scopus and CINAHL databases for studies published between January 1, 1980, and 30 April 30, 2013, which compared pre-hospital use of ETI with SGA for outcomes of return of spontaneous circulation (ROSC); survival to hospital admission; survival to hospital discharge; and favorable neurological or functional status. We selected studies using pre-specified criteria. Included studies were independently screened for quality using the Newcastle-Ottawa scale. We did not pool results because of study variability. Study outcomes were extracted and results presented as summed odds ratios with 95% CI.ResultsWe identified five eligible studies: one quasi-randomized controlled trial and four cohort studies, involving 303,348 patients in total. Only three of the five studies reported a higher proportion of ROSC with ETI versus SGA with no difference reported in the remaining two. None found significant differences between ETI and SGA for survival to hospital admission or discharge. One study reported better functional status at discharge for ETI versus SGA. Two studies reported no significant difference for favorable neurological status between ETI and SGA.ConclusionCurrent evidence does not conclusively support the superiority of ETI over SGA for multiple outcomes among adults with OHCA.

Team-focused Cardiopulmonary Resuscitation: Prehospital Principles Adapted for Emergency Department Cardiac Arrest Resuscitation

“…Two recent large observational studies suggest a small but statistically significant benefit for ETI over supraglottic BIAD in OHCA (29,30). One systematic review published in 2014 (including 303,348 patients with OHCA from 5 eligible studies) concluded that the current evidence did not conclusively support the superiority of ETI over supraglottic BIAD (31). However, a metaanalysis published in 2015 (including 75,649 patients with OHCA from 10 eligible studies) concluded that patients receiving ETI were more likely to obtain ROSC, survive to hospital admission, and survive neurologically intact than patients treated with supraglottic BIAD (32).…”

“…Airway management in cardiac arrest remains a controversial topic with a paucity of available in-hospital data. Large observational trials from the prehospital setting have shown mixed results among head-to-head comparisons between bag-valve-mask ventilation and advanced airway placement, including supraglottic BIAD and ETI (28)(29)(30)(31)(32). A large Japanese study of 649,359 patients with OHCA showed increased neurologically intact survival with bagvalve-mask alone when compared to advanced airway placement (28).…”

Scandinavian SSAI clinical practice guideline on pre‐hospital airway management

“…In OHCA, an SAD has for long been an alternative to ETI but effect on outcome is debated . Few studies (no RCTs) compare results of resuscitation with different strategies for airway management.…”

Influence of prehospital airway management on neurological outcome in patients transferred to a heart attack centre following out‐of‐hospital cardiac arrest

“…The optimal airway management strategy in out‐of‐hospital cardiac arrest remains unclear . Some investigators report improved survival where endotracheal intubation (ETI) is performed by paramedics in cardiac arrest, whereas others have observed increased mortality .…”