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.

Conclusion

• 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

Interventions

• 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
    • 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

Outcome

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

Criticisms

• 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

Funding

• 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.

Authors:

Michael Holtz, Daniel Ostermayer, Alison Panosian, Ross Donaldson