Supraglottic airway resuscitation likely more or just as effective as endotracheal intubation for out-of-hospital cardiac arrest

1. In an American, randomized controlled trial, supraglottic airway (SGA) resuscitation was associated with marginally better neurological outcomes and 72-hour survival compared to endotracheal intubation (ETI) for patients with out-of-hospital cardiac arrests (OHCA).

2. However, a similar English randomized controlled trial found no difference in favorable neurological outcomes 30 days after OHCA between SGA or ETI.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Though out-of-hospital cardiac arrests (OHCA) that require resuscitation are often fatal, timely emergency services are able increase survival. However, it is still unclear what the optimal airway management should be, especially between supraglottal airway (SGA) and endotracheal intubation (ETI) approaches. Two randomized controlled trials from the United States and England compared SGA and ETI for OHCA across multiple paramedic teams. In the American trial, SGA was associated with marginally better neurological outcomes and 72-hour survival compared to ETI while the British trial found no difference in favorable neurological outcomes after 30 days. Both trials noted quicker and fewer attempts at securing an airway with SGA compared to ETI.

Though previous population based studies have suggested ETI may be more effective than SGA for OHCA, these two well-designed and well-powered studies suggest that SGA is similar to and may be slightly more effective than ETI. In addition, the pragmatic design and randomization is a major strength compared to previous studies.

Click here to read the study in JAMA

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In-Depth [randomized controlled trial]: The Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART) recruited 27 American EMS agencies and 3004 patients from December 2015 to November 2017. Paramedics were randomized 1:1 to a crossover design to administer laryngeal tube SGA or ETI resuscitation to patients 18 or older who suffered an OHCA. The 72-hour survival was greater in those who received SGA compared to ETI resuscitation (difference 2.9%; CI95 0.3 to 5.6%). SGA also led to improved return of circulation (adjusted difference 3.6%; CI95 0.3 to 6.8%), hospital survival (adjusted difference 2.7%; CI95 0.6 to 4.8%), and favorable neurological status at discharge (adjusted difference 2.1%; CI95 0.3% to 3.8%). ETI was associated with a greater chance of 3 or more airway insertion attempts (18.9 vs 4.5%) and more unsuccessful initial airway attempts than SGA (44.1 vs 11.8%).

The English AIRWAYS-2 trial recruited 4 EMS agencies covering 40% of the national population and recruited 9296 patients from June 2015 to August 2017. The favorable neurological outcomes were similar between SGA and ETI at 30-days after OHCA (risk difference −0.2%; CI95 −0.6 to 0.3). However, in the 7576 who received advanced airway management, SGA resulted in more favorable neurological outcomes than ETI (risk difference 1.4%; CI95 0.5 to 2.2%). SGA was more successful in achieving ventilation after two attempts than ETI (risk difference 2.1%; CI95 1.2 to 2.9%).

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