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Airway management for out-of-hospital cardiac arrest under debate
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Cardiopulmonary resuscitation with advanced airway management, such as endotracheal intubation, yields poor neurological outcomes in patients with out-of-hospital cardiac arrest, researchers reported in JAMA.
Recent studies have challenged the survival benefit of advanced airway management as compared with conventional bag-valve-mask ventilation in this population and clinical setting. For this study, researchers studied 649,359 adults in Japan who had an out-of-hospital cardiac arrest. Patients were resuscitated by emergency responders and then sent to a medical institution.
Effect on neurological outcomes, survival
Fifty-seven percent received bag-valve-mask ventilation and 43% received advanced airway management, including 6% with endotracheal intubation and 37% with use of supraglottic airways.
In the full cohort, neurologic survival rates were 1% for the endotrachial intubation group, 1.1% for the supraglottic airway group and 2.9% in the bag-valve-mask ventilation group. The advanced airway group had 62% lower odds of favorable neurological outcome compared with the bag-valve-mask group (adjusted OR=0.38; 95% CI, 0.37-0.4). Endotracheal intubation and supraglottic airways were both associated with lower odds of neurologically favorable survival (adjusted OR=0.41; 95% CI, 0.37-0.45 and OR=0.38; 95% CI, 0.36-0.4, respectively).
The researchers also analyzed a propensity score-matched cohort of 357,228 patients. In this cohort, the odds of neurologically favorable survival were lower for both endotracheal intubation (adjusted OR=0.45; 95% CI, 0.37-0.55) and supraglottic airways (adjusted OR=0.36; 95% CI, 0.33-0.39).
‘Reconsider the approach’
Kohei Hasewaga, MD, MPH, of the department of emergency medicine at Massachusetts General Hospital and Harvard Medical School, and colleagues concluded: “Our observations contradict the assumption that aggressive airway intervention is associated with improved outcomes and provide an opportunity to reconsider the approach to prehospital airway management in this population.”
Survival rates after out-of-hospital cardiac arrest have increased in recent years due to advances in care, but recent estimates suggest that the rate is low, at 8% to 10%.
In an accompanying editorial, Henry E. Wang, MD, MS, from the department of emergency medicine at University of Alabama School of Medicine, and Donald M. Yealy, MD, from the department of emergency medicine at University of Pittsburgh, said these data send “a clear message.
“Emergency medical services professional across the world must engage in the scientific process,” Wang and Yealy wrote. “A large, well-designed research effort is needed to define the benefit from endotracheal intubation, supraglottic airway insertion or more simple actions during resuscitation after cardiac arrest.”
For more information:
Hasegawa K. JAMA. 2013;doi:10.1001/jama.2012.187612.
Wang HE. JAMA. 2013;doi:10.1001/jama.2012.216998.
Disclosure:The researchers report receiving a grant from the Fire and Disaster Management Agency. Wang reports no relevant financial disclosures; Yealy reports receiving funding from Wolters Kluwer.