Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest

      Abstract

      Objective

      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.

      Methods

      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-h 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.

      Results

      Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (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-h 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).

      Conclusions

      In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.

      Keywords

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      References

        • Wang H.E.
        • Yealy D.M.
        Out-of-hospital endotracheal intubation: where are we?.
        Ann Emerg Med. 2006; 47: 532-541
        • Wang H.E.
        • Lave J.R.
        • Sirio C.A.
        • Yealy D.M.
        Paramedic intubation errors: isolated events or symptoms of larger problems?.
        Health Aff (Millwood). 2006; 25: 501-509
        • Wang H.E.
        • Kupas D.F.
        • Paris P.M.
        • Bates R.R.
        • Yealy D.M.
        Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation.
        Resuscitation. 2003; 58: 49-58
        • Dunford J.V.
        • Davis D.P.
        • Ochs M.
        • Doney M.
        • Hoyt D.B.
        Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation.
        Ann Emerg Med. 2003; 42: 721-728
        • Katz S.H.
        • Falk J.L.
        Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
        Ann Emerg Med. 2001; 37: 32-37
        • Wang H.E.
        • Simeone S.J.
        • Weaver M.D.
        • Callaway C.W.
        Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.
        Ann Emerg Med. 2009; 54: 645e1-652e1
        • Gahan K.
        • Studnek J.R.
        • Vandeventer S.
        King LT-D use by urban basic life support first responders as the primary airway device for out-of-hospital cardiac arrest.
        Resuscitation. 2011;
        • Braude D.
        • Richards M.
        Rapid Sequence Airway (RSA) – a novel approach to prehospital airway management.
        Prehosp Emerg Care. 2007; 11: 250-252
        • Davis D.P.
        • Valentine C.
        • Ochs M.
        • Vilke G.M.
        • Hoyt D.B.
        The Combitube as a salvage airway device for paramedic rapid sequence intubation.
        Ann Emerg Med. 2003; 42: 697-704
        • Guyette F.X.
        • Greenwood M.J.
        • Neubecker D.
        • Roth R.
        • Wang H.E.
        Alternate airways in the prehospital setting (resource document to NAEMSP position statement).
        Prehosp Emerg Care. 2007; 11: 56-61
        • Abo B.N.
        • Hostler D.
        • Wang H.E.
        Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?.
        Resuscitation. 2007; 72: 234-239
        • Stiell I.G.
        • Nichol G.
        • Leroux B.G.
        • et al.
        Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.
        N Engl J Med. 2011; 365: 787-797
        • Aufderheide T.P.
        • Nichol G.
        • Rea T.D.
        • et al.
        A trial of an impedance threshold device in out-of-hospital cardiac arrest.
        N Engl J Med. 2011; 365: 798-806
        • Newgard C.D.
        • Sears G.K.
        • Rea T.D.
        • et al.
        The Resuscitation Outcomes Consortium Epistry—Trauma: design, development, and implementation of a North American epidemiologic prehospital trauma registry.
        Resuscitation. 2008; 78: 170-178
        • Morrison L.J.
        • Nichol G.
        • Rea T.D.
        • et al.
        Rationale, development and implementation of the Resuscitation Outcomes Consortium Epistry—Cardiac Arrest.
        Resuscitation. 2008; 78: 161-169
        • Davis D.P.
        • Garberson L.A.
        • Andrusiek D.L.
        • et al.
        A descriptive analysis of Emergency Medical Service Systems participating in the Resuscitation Outcomes Consortium (ROC) network.
        Prehosp Emerg Care. 2007; 11: 369-382
        • Burton J.H.
        • Baumann M.R.
        • Maoz T.
        • Bradshaw J.R.
        • Lebrun J.E.
        Endotracheal intubation in a rural EMS state: procedure utilization and impact of skills maintenance guidelines.
        Prehosp Emerg Care. 2003; 7: 352-356
        • Rittenberger J.C.
        • Raina K.
        • Holm M.B.
        • Kim Y.J.
        • Callaway C.W.
        Association between Cerebral Performance Category Modified Rankin Scale, and discharge disposition after cardiac arrest.
        Resuscitation. 2011; 82: 1036-1040
        • Segal N.
        • Yannopoulos D.
        • Mahoney B.D.
        • et al.
        Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest.
        Resuscitation. 2012; 83: 1024-1029
        • Richards C.F.
        Piriform sinus perforation during Esophageal–Tracheal Combitube placement.
        J Emerg Med. 1998; 16: 37-39
        • Vezina D.
        • Lessard M.R.
        • Bussieres J.
        • Topping C.
        • Trepanier C.A.
        Complications associated with the use of the Esophageal–Tracheal Combitube.
        Can J Anaesth. 1998; 45: 76-80
        • Lefrancois D.P.
        • Dufour D.G.
        Use of the esophageal tracheal Combitube by basic emergency medical technicians.
        Resuscitation. 2002; 52: 77-83
        • Cady C.E.
        • Weaver M.D.
        • Pirrallo R.G.
        • Wang H.E.
        Effect of emergency medical technician-placed Combitubes on outcomes after out-of-hospital cardiopulmonary arrest.
        Prehosp Emerg Care. 2009; 13: 495-499
        • Kajino K.
        • Iwami T.
        • Kitamura T.
        • et al.
        Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest.
        Crit Care. 2011; 15: R236
        • Wang H.E.
        • Balasubramani G.K.
        • Cook L.J.
        • Lave J.R.
        • Yealy D.M.
        Out-of-hospital endotracheal intubation experience and patient outcomes.
        Ann Emerg Med. 2010; 55 (e6): 527-537
        • Johnston B.D.
        • Seitz S.R.
        • Wang H.E.
        Limited opportunities for paramedic student endotracheal intubation training in the operating room.
        Acad Emerg Med. 2006; 13: 1051-1055
        • Wang H.E.
        • Kupas D.F.
        • Hostler D.
        • Cooney R.
        • Yealy D.M.
        • Lave J.R.
        Procedural experience with out-of-hospital endotracheal intubation.
        Crit Care Med. 2005; 33: 1718-1721
        • Wang H.E.
        • Seitz S.R.
        • Hostler D.
        • Yealy D.M.
        Defining the learning curve for paramedic student endotracheal intubation.
        Prehosp Emerg Care. 2005; 9: 156-162
        • Hanif M.A.
        • Kaji A.H.
        • Niemann J.T.
        Advanced airway management does not improve outcome of out-of-hospital cardiac arrest.
        Acad Emerg Med. 2010; 17: 926-931
        • Studnek J.R.
        • Thestrup L.
        • Vandeventer S.
        • et al.
        The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients.
        Acad Emerg Med. 2010; 17: 918-925
        • Bobrow B.J.
        • Clark L.L.
        • Ewy G.A.
        • et al.
        Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
        JAMA. 2008; 299: 1158-1165
        • Aufderheide T.P.
        • Lurie K.G.
        Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
        Crit Care Med. 2004; 32: S345-S351
        • Aufderheide T.P.
        • Sigurdsson G.
        • Pirrallo R.G.
        • et al.
        Hyperventilation-induced hypotension during cardiopulmonary resuscitation.
        Circulation. 2004; 109: 1960-1965
        • Wang H.E.
        • Bogucki S.
        Out-of-hospital endotracheal intubation: are observational data useful?.
        Acad Emerg Med. 2010; 17: 987-988