Tracheal Intubation vs Supraglottic Airway Device in Out-of-Hospital Cardiac Arrest

Persons experiencing out-of-hospital cardiac arrests who were treated with supraglottic airway devices as their initial airway management strategy did not have favorable 30-day functional outcomes, according to a study published in JAMA.

The optimal form of out-of-hospital airway management during cardiac arrest is unknown. The current study’s objective was to assess whether a supraglottic airway device was superior to tracheal intubation in adults suffering an out-of-hospital, nontraumatic cardiac arrest through a cluster randomized, multicenter clinical trial of paramedics working in England. From June 2015 to August 2017, with follow-up concluding in February 2018, 9296 participants were treated by 759 paramedics randomly assigned to use a supraglottic airway device as their initial airway management strategy, and 764 paramedics randomly assigned to use tracheal intubation. Ultimately, 4886 individuals received treatment with a supraglottic airway device and 4410 were treated with tracheal intubation.

The primary outcome was a modified Rankin Scale score (0-3=good outcome, 4-6=poor outcome to death) at 30 days after cardiac arrest or at hospital discharge, whichever came first, and secondary outcomes were success of ventilation, aspiration, and regurgitation.

Of the 9296 study participants, 9289 had known modified Rankin Scale Scores. Of the 4882 people in the supraglottic airway device group, 311 (6.4%) had good outcomes vs 300 (6.8%) of the 4407 people in the tracheal intubation group (adjusted risk difference, –0.6%; 95% CI, –1.6% to 0.4%). In the supraglottic airway device group, initial ventilation was successful in 87.4% of participants (4255 of 4868) compared with 79.0% of participants (3473 of 4397) in the tracheal intubation group (adjusted risk difference, 8.3%; 95% CI, 6.3%-10.2%). However, persons treated by paramedics using tracheal intubation were less likely to receive advanced airway management (77.6% of participants [3419 of 4404]) vs those treated by paramedics using supraglottic airway devices ((85.2% of participants [4161 of 4883]). Rates of regurgitation and aspiration were not significantly different between the groups.  

The investigators concluded, “Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.”

Reference

Benger JR, Kirby K, Black S, et al. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. JAMA. 2018;320(8):779-791. doi:10.1001/jama.2018.11597