Spotlight on Research

Tim Edwards
Monday, June 2, 2014

Is less sometimes more? Airway management in cardiac arrest…In this retrospective database analysis, McMullan and colleagues reviewed the Cardiac Arrest Registry to Enhance Survival (CARES) registry for 2011 to determine the influence of airway management approach on rates of sustained return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge and survival to hospital discharge with good neurological outcome (Cerebral Performance Category 1 or 2).The CARES registry collates data relating to cardiac arrest from 400 emergency medical service (EMS) agencies across the USA. This analysis included adults (age ≥18 years) and excluded cases where age was unknown or not reported and where airway management data were not reported or the device used was listed as ‘other’. Cases were classified as receiving endotracheal intubation (ETI), supragalottic airway (SGA) insertion or no advanced airway. SGA devices used by participating agencies include King Laryngeal Tube, Combitube and Laryngeal Mask Airway (LA). Cases where ETI or SGA insertion failed were classified as no advanced airway.Outcome analyses compared ETI versus SGA, and no advanced airway management versus advanced airway management (SGA or ETI). During 2011 there were 12 875 cardiac arrests reported. Children (n=256), patients where age was unknown (n=83) and cases where the EMS agency did not provide airway management details (n=1,847) were excluded from analysis.An advanced airway was placed in over 80% of the remaining 10 691 patients, with approximately two-thirds undergoing ETI. The King airway was the most commonly used device in the third of patients managed via SGA. Patients undergoing ETI were more likely to be male and older and less likely to receive public access defibrillation. Patients receiving no advanced airway were more likely to have a cardiac arrest in a public location or healthcare facility and to have their arrest witnessed by EMS staff and present with a shockable arrest rhythm.ETI was independently associated with increased adjusted odds of sustained ROSC, survival to hospital admission, hospital survival and good neurological outcome when compared with SGA insertion. Stratification of outcomes according to presenting arrest rhythm revealed that these associations persisted for patients in shockable rhythms only. Patients with no advanced airway intervention demonstrated higher adjusted odds of survival when compared with those receiving ETI or SGA.These results must be interpreted with caution given some of the methodological limitations associated with this study. The CARES registry does not provide data relating to number of attempts at advanced airway insertion; therefore, it is not clear in how many cases a SGA was inserted as a rescue device following ETI failures that might be expected to result in worse outcomes. Patients who did not receive advanced airway management may also represent a group in whom ROSC was achieved more rapidly, negating the need for such intervention and representing a group with potentially higher survivability. Similarly, in-hospital data relating to potential confounders such as use of mild therapeutic hypothermia and percutaneous coronary intervention are lacking. Nonetheless, these findings again challenge the assumption that SGA devices are a universal alternative to ETI in out-of-hospital cardiac arrest.

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