AIRWAYS-2 – SGA vs ETT for Out-of-Hospital Cardiac Arrest

October 17, 2018

Written by Clay Smith

Spoon Feed
There was no difference in good neurological recovery after non-traumatic out-of-hospital cardiac arrest (OHCA) at 30 days with use of an i-gel supraglottic airway (SGA) compared to endotracheal tube (ETT).

Why does this matter?
Prehospital airway management has variable success.  Often air crews have high success, but ground crews less so.  In arrest, there is observational evidence that a SGA may worsen outcome.  We know early airway management with an ETT is bad in children and adults.  We also know bag-mask ventilation was as good as ETI.  Yesterday, we discussed use of a laryngeal tube (LT) vs ETT, and the results favored the LT.  What about the i-gel (a type of laryngeal mask airway) SGA vs ETT?

What AIRWAYS-2 place?
This was a multi-center cluster randomized trial of airway management with either a SGA (i-gel) or ETT in 9,296 adult patients with non-traumatic OHCA placed by 1,523 paramedics.  This study was even larger than the LT vs ETT RCT yesterday.  For the primary outcome of good neurological outcome at 30-days or hospital discharge (mRS 0-3), there was no difference in SGA vs ETT, each around 6-7%, not statistically different.  Successful ventilation on the first try was greater in the SGA group, 87.4%; 79% for the ETT group.  There was no difference in the complication of regurgitation or aspiration between the groups.  Another issue was paramedic device preference and confidence.  “Paramedics randomized to use tracheal intubation were less likely to use advanced airway management than paramedics randomized to use the supraglottic airway device.”  The same was true in yesterday’s LT trial.  Paramedics seemed to prefer SGA devices over ETI.

After covering both of these important JAMA articles, I agree with the editorialists’ conclusion.  Despite the limitations of both studies, “EMS personnel and physicians involved with protocol development for EMS systems in the United States, United Kingdom, and similar settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”  It is very difficult to acquire and maintain the skill of ETI, especially during CPR, as we will see in tomorrow’s article.

Another Spoonful

• FOAMfrat has interviews with the lead authors of PART and AIRWAYS-2.

• The Bottom Line takes a deep dive and has an amazing infographic.

• Catch the Resus Room podcast on this.

• EMLoN has a quick, incisive analysis of both prehospital studies.

• Journal of EMS weighs in

• REBEL EM interviews Ashley Liebig

• JWatch concluded, Maybe Paramedics Should Not Perform ETI (subscription required)

Source
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 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597.

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