Airway Management Methods During ACLS: Jury Still Out

Out of hospital cardiac arrest
Out of hospital cardiac arrest
A study sought to determine whether bag-mask ventilation was noninferior to endotracheal intubation as initial airway management during advanced cardiac life support during out-of-hospital cardiac arrest.

Bag-mask ventilation (BMV) failed to demonstrate noninferiority or inferiority for survival compared with endotracheal intubation (ETI) in patients with out-of-hospital cardiorespiratory arrest (OHCA), according to the results of a study published in JAMA.

Patricia Jabre, MD, PhD, from the Service d’Aide Médicale d’Urgence de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France, and colleagues conducted a multicenter randomized clinical trial comparing BMV and ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium between March 9, 2015 and January 2, 2017. Follow-up was concluded January 26, 2017.

The primary outcome was favorable neurological outcome examined, defined as cerebral performance category 1 or 2 at 28 days postcirculatory arrest. The investigators chose a noninferiority margin of 1%. Secondary outcomes included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI/BMV difficulty or failure.

Favorable functional survival at day 28 occurred in 44 (4.3%) of 1018 patients in the BMV group and 43 (4.2%) of 1022 patients in the ETI group (P for noninferiority =.11). Survival to hospital admission was 294 (28.9%) in the BMV group compared with 333 (32.6%) in the ETI group, and global survival at day 28 was 55 (5.4%) in the BMV group compared with 54 (5.3%) in the ETI group. These differences were not significant.

Complications included difficult airway management, at 18.1% in the BMV group compared with 13.4% in the ETI group (P =.004); failure, at 6.7% in the BMV group compared with 2.1% in the ETI group (P <.001); and regurgitation of gastric content, at 15.2% in the BMV group compared with 7.5% in the ETI group (P <.001).

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The authors concluded that a determination of equivalence of superiority between these techniques requires further research. Among the limitations of this study was the failure to include comparison of inpatient management after cardiac arrest, which may have varied considerably.


Jabre P, Penaloza A, Pinero D, et al. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest. A randomized clinical trial. JAMA. 2018;319:779-787. doi:10.1001/jama.2018.0156