Prehospital Advanced Airway Techniques Associated With Poor Outcome in Out-of-Hospital Cardiac Arrest
summary
This abstract is available on the publisher's site.
Access this abstract nowAdvances in the care of patients with out-of-hospital cardiac arrest (OHCA) have been made, with improvements noted in early access to emergency medical care, early cardiopulmonary resuscitation (CPR), rapid defibrillation, and integrated care post cardiac arrest. However, the survival rate remains low, with recent estimates at about 8% to 10%.
Advanced airway interventions, such as endotracheal intubation or insertion of supraglottic airways, have long been used to manage patients with OHCA. The survival benefit of such aggressive interventions compared with conventional bag-valve-mask ventilation has been challenged in this clinical setting. In the absence of large-scale studies focusing on the association between advanced airway management and patient-centered outcomes such as neurologic status, Hasegawa and colleagues conducted a prospective population-based study in Japan to assess whether CPR via advanced airway techniques is more or less effective than CPR via conventional bag-valve-mask ventilation in caring for adults with OHCA.
Included in the study were 367,837 patients who underwent bag-valve-mask ventilation and 281,522 who underwent advanced airway management. Of those in the advanced airway management group, 41,972 received endotracheal intubation and 239,550 received supraglottic airway insertion. All of the participants were at least 18 years old, had undergone resuscitation by emergency medical service (EMS) personnel, and were subsequently transported to medical institutions.
Favorable neurologic outcome 1 month after cardiac arrest was the primary study endpoint. Glasgow-Pittsburgh cerebral performance categories 1 (good performance) and 2 (moderate disability) were considered favorable outcomes, whereas categories 3 (severe cerebral disability), 4 (vegetative state), and 5 (death) were considered unfavorable outcomes. Return of spontaneous circulation before arrival at the hospital and 1-month survival were deemed secondary outcomes measures.
According to the unadjusted model, significant negative associations were noted between advanced airway management (regardless of technique) and the three endpoint measures (P < .001 for all). The overall rate of neurologically favorable survival was 2.2% (95% CI, 2.1%–2.2%). In the bag-valve-mask intubation group, the rate of neurologically favorable survival was 2.9% (95% CI, 2.9%–3.0%), compared with 1.0% (95% CI, 0.9%–1.1%) in the endotracheal intubation group and 1.1% (95% CI, 1.1%–1.2%) in the supraglottic airway group. Overall, the rates of return of spontaneous circulation and 1-month survival were 6.5% (95% CI, 6.5%–6.6%) and 4.7% (95% CI, 4.7%–4.8%), respectively. Similarly, according to the adjusted model, both advanced airway techniques were independent negative predictors of all three outcomes (P < .001 for all).
Click on any of these tags to subscribe to Topic Alerts. Once subscribed, you can get a single, daily email any time PracticeUpdate publishes content on the topics that interest you.
Visit your Preferences and Settings section to Manage All Topic Alerts
Additional Info
Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-Of-Hospital Cardiac Arrest
JAMA 2013 Jan 16;309(3)257-266, K Hasegawa, A Hiraide, Y Chang, DF BrownFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
For many years, cardiopulmonary resuscitation (CPR) has emphasized the ABCs in management: airway, breathing, and circulation. As these two articles emphasize, it is now clear that circulation is THE most important part of CPR. Early, effective, and continuous chest compression at 100/minute is the key to increasing survival and any delay—such as taking time from chest compression for airway management—should be avoided. Consistent with the emphasis on circulation is the resumption of an organized heart rhythm. So, early cardioversion/defibrillation is mandatory as well. Because the quandaries of mouth-to-mouth or mouth-to-mask techniques and intubation are now banished, the life-saving application of CPR techniques that can meaningfully improve survival are within the capabilities of the lay public. Considering that there are over 300,000 sudden cardiac arrests (SCA) annually in the US, that SCAs account for about half of all cardiovascular deaths, that 50% of SCAs are the first clinical expression of heart disease, that 80% occur in the home, and that the overall survival to leaving the hospital is around 5%, life-saving advances are clearly needed. Widespread availability of AEDs and emphasis on chest compression can help turn the tide on this appalling scourge.