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Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome
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Benger, Jonathan R., Kirby, Kim, Black, Sarah, Brett, Stephen J., Clout, Madeleine, Lazaroo, Michelle J., Nolan, Jerry P., Reeves, Barnaby C., Robinson, Maria, Scott, Lauren J., Smartt, Helena, South, Adrian, Stokes, Elizabeth A., Taylor, Jodi, Thomas, Matthew, Voss, Sarah, Wordsworth, Sarah and Rogers, Chris A. (2018) Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome. JAMA: The Journal of the American Medical Association, 320 (8). pp. 779-798. doi:10.1001/jama.2018.11597 ISSN 0098-7484.
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Official URL: http://dx.doi.org/10.1001/jama.2018.11597
Abstract
Importance
The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.
Objective
To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
Design, Setting, and Participants
Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.
Interventions
Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.
Main Outcomes and Measures
The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.
Results
A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], −0.6% [95% CI, −1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, −0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, −1.5% to 1.8%]).
Conclusions and Relevance
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.
| Item Type: | Journal Article | ||||||
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| Subjects: | R Medicine > RC Internal medicine R Medicine > RF Otorhinolaryngology |
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| Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Clinical Trials Unit Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School |
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| Library of Congress Subject Headings (LCSH): | Cardiac arrest -- Treatment, Trachea -- Intubation | ||||||
| Journal or Publication Title: | JAMA: The Journal of the American Medical Association | ||||||
| Publisher: | American Medical Association | ||||||
| ISSN: | 0098-7484 | ||||||
| Official Date: | 28 August 2018 | ||||||
| Dates: |
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| Volume: | 320 | ||||||
| Number: | 8 | ||||||
| Page Range: | pp. 779-798 | ||||||
| DOI: | 10.1001/jama.2018.11597 | ||||||
| Status: | Peer Reviewed | ||||||
| Publication Status: | Published | ||||||
| Access rights to Published version: | Open Access (Creative Commons) | ||||||
| Date of first compliant deposit: | 5 February 2019 | ||||||
| Date of first compliant Open Access: | 28 February 2019 | ||||||
| RIOXX Funder/Project Grant: |
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