This latest update in Resuscitation journal on tracheal intubation versus supraglottic airways in out of hospital cardiac arrest is intriguing. Most countries’ resuscitation guidelines were updated over 12 months ago with consensus statements from major bodies like ILCOR and AHA. The de-emphasis on tracheal intubation and advice that supraglottic airway devices were equivalent to ETI, were prominent changes. Indeed Wang published research only last year seeming to indicate the exact opposite, that prehospital ETI in cardiac arrest was associated with worse outcomes! read this Resuscitation editorial to find out more !
Whats my take on all the evidence for and against what we should be doing in prehospital cardiac arrest airway management? BVM and basic airway manoeuvres should be bread and butter mainstay. A supraglottic airway is fine to start your resuscitation as well. Its easy and quick to place and protects the airway to a reasonable degree. Ideally the next step should be converting to a cuffed tracheal tube, without interrupting CPR. I think this is the key.
Endotracheal Intubation versus Supraglottic Airway Insertion in Out-
of-Hospital Cardiac Arrest
Wang et al, online Jun 2012, Resuscitation.
To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA.
We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-hour survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders.
Of 10,455 adult OHCA, 8,487 (81.2%) received ETI and 1,968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-hour survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16).
In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.