Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest

Abstract

IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3-to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score Յ3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

Comparison of videolaryngoscopy and direct laryngoscopy by German paramedics during out-of-hospital cardiopulmonary resuscitation; an observational prospective study

“…Based on the variability of individual intubation experience among paramedics in this single EMS, the results cannot be transferred to another EMS. Furthermore, our study was conducted over 4 years and there has possibly been an increase in SGA use by paramedics, because more recent studies indicated that SGAs could be equivalent or better than ETI [28,29]. This might have also an effect on the small number of cases in the whole investigation period.…”

Endotracheal intubation during out‐of‐hospital cardiac arrest: New insights from recent clinical trials

“…The Pragmatic Airway Resuscitation Trial (PART) involved 27 US advanced life support EMS agencies from the Birmingham (Alabama), Dallas‐Fort Worth, Milwaukee, Pittsburgh, and Portland (Oregon) sites of the ROC . The trial included adult OHCA patients who required BVM ventilation or advanced airway insertion.…”

“…In this paper, we summarize the rationale for, results of, and lessons from the Pragmatic Airway Resuscitation Trial (PART), the AIRWAYS-2 trial, and the Cardiac Arrest Airway Management (CAAM) trial. [6][7][8]…”

Advancing emergency airway management practice and research

“…The milestone of emergency airway management is the foundation of the National Emergency Airway Registry (NEAR) – a multicenter registry that aims to prospectively characterize the emergency airway management practices in the EDs across North America . Since its inception, the knowledge based on other large multicenter registries, including the Korean Emergency Airway Management Registry (KEAMR) and Japanese Emergency Airway Network (JEAN) registry, have also advanced the ED airway management, in parallel to the advent of intubation techniques and devices, such as rapid sequence intubation (RSI), video laryngoscopies (VLs), and supraglottic devices . Consequently, the performance of emergency airway management with the use of these approaches is indicative of the competence of emergency physicians managing the critically ill.…”