EBQ:Japanese OHCA Prehospital Airway Management Trial

incomplete Journal Club Article
Hasegawa, K et al. "Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest". JAMA. 2012. 309 (3)(187612):257–266.
PubMed Full text PDF

Clinical Question

  • Do patients with out of hospital cardiac arrest have more favorable neurological outcome with advanced airway management by EMS compared to conventional bag-valve-mask ventilation?
  • Authors hypothesized that both supraglottic and endotracheal intubation would be associated with more favorable neurologic outcomes.


  • Advanced airway of any type was independently associated with decreased odds of neurologically favorable survival compared to BVM ventilation

Major Points

  • Advanced airway management during OHCA and CPR was independently associated with a decreased likelihood of favorable neurological outcome when compared to BVM management
    • This negative association cannot prove causality
  • Regression models using Propensity matched patients favored BVM when compared to both endotracheal intubation and supraglottic airway management in terms of obtaining ROSC prior to arrival at the hospital, 1-month survival, and neurologically favorable survival

Inclusion Criteria

  • January 1, 2005 to December 31, 2010
  • Japanese EMS database
  • 18 years older who had out of hospital cardiac arrest
  • Resuscitation was attempted by EMS and patient was transported to hospital

Exclusion Criteria

  • No age recorded for cardiac arrest
  • Out of hospital airway management not documented


  • Advanced airway devices placed by EMTs
    • Endotracheal intubation
    • Supraglottic airway
    • EMTs able to place advanced airway had received specialized training as quoted in the paper here[1]
      • Laryngeal mask airway, laryngeal tube, or esophageal-tracheal twin lumen airway device
  • Providers had 2 attempts to place airway device
  • Advanced airway confirmed with end-tidal CO2 and/or esophageal detection device


Primary Outcomes

  • Favorable neurological outcome at 1 month after cardiac arrest
    • Favorable neurological outcome considered a Glasgow-Pittsburgh cerebral performance category of 1 or 2
    • Overall: 2.2%
    • BVM: 2.9%
    • Advanced Airway: 1.1%
      • Endotracheal Intubation: 1.0%
      • Supraglottic Airway: 1.1%
    • Odds Ratio (95% CI) Advanced Airway vs. BVM: 0.38 (0.36-0.39)
  • Glasgow-Pittsburgh cerebral performance categories:
    • Category 1 (good performance)
    • Category 2 (moderate disability)
    • Category 3 (severe disability)
    • Category 4 (vegetative state)
    • Category 5 (death)

Secondary Outcomes

  • Return of spontaneous circulation before hospital arrival
    • Overall: 6.5%
    • BVM: 7.0%
    • Advanced Airway: 5.8%
      • Endotracheal Intubation: 8.4%
      • Supraglottic Airway: 5.3%
    • Odds ratio (95% CI) Advanced Airway vs BVM: 0.81 (0.79-0.83)
  • One-month survival
    • Overall 4.7%
    • BVM: 5.3%
    • Advanced Airway: 3.9%
      • Endotracheal Intubation: 4.2%
      • Supraglottic Airway: 3.8%
    • Odds ratio (95% CI) Advanced Airway vs BVM: 0.72 (0.70-0.73)

Subgroup analysis

  • Advanced airway versus bag-valve-mask ventilation
  • Endotracheal intubation or supraglottic airway versus bag-valve-mask ventilation


  • Not a randomized and there is potential selection bias and confounding
  • Generalization difficult for U.S. based EMS given different training for EMT's, different population, and different protocols
  • Details regarding the process of information were not available
  • It is possible that patients who received BVM only had ROSC sooner and therefore did not require advanced airway management
    • It can be theorized that this subset of patients would have better neurological outcomes


  • Grant support to Dr. Hiraide for emergency management scientific research from the Fire and Disaster Management Agency.
  • The Fire and Disaster Management Agency gathered and managed the data but had no role in the design and conduct of the study; analysis and interpretation of the data; or preparation, review, or approval of the manuscript.


  1. Ambulance Service Planning Office of Fire and Disaster Management Agency of Japan. Airway Management With Endotracheal Intubation by Emergency Life Saving Technicians. 2004. http://www.mhlw.go.jp/shingi/2009/03/dl/s0325-12g_0001.pdf.