Written by Sam Parnell
For adults with out-of-hospital cardiac arrest (OHCA), initial laryngeal tube (LT) insertion by EMS providers was associated with improved 72-hour survival, return of spontaneous circulation (ROSC), hospital survival, favorable neurologic outcome, and airway success compared to initial endotracheal tube (ETT) insertion.
Why does this matter?
Endotracheal intubation (ETI) has been a cornerstone of EMS care for OHCA. However, there are multiple challenges with paramedic ETI including insertion failure, need for several attempts, and significant interruptions in compressions. In addition, this is a relatively rare EMS procedure, with many U.S. paramedics only performing one procedure annually. We also know bag-mask ventilation was as good as ETI. Supraglottic airway (SGA) devices, such as the LT, are an appealing alternative to ETI during OHCA, as insertion is quick, simple, and require less training. Today’s study called PART - Pragmatic Airway Resuscitation Trial - focuses on the LT; tomorrow’s study, AIRWAYS-2, will cover use of the i-gel SGA for OHCA.
Should we put the tube in the trachea or larynx?
This was a multi-center, pragmatic, cluster-crossover, randomized trial of 3004 adults with OHCA comparing initial airway management by paramedics of LT insertion vs ETI by 27 different EMS agencies in the U.S. from December 1, 2015 to November 4, 2017. The primary outcome was 72-hour survival, which was 18.3% for the LT group and 15.4% in the ETI group (P = 0.04; RR 1.19). Secondary outcomes also favored the LT group vs ETI group including ROSC (27.9% vs 24.3%; P = 0.03), hospital survival (10.8% vs 8.1%; P = 0.01), and favorable neurological status at discharge (7.1% vs 5.0%; P = 0.02). In addition, ETI had increased risk of adverse events compared to LT insertion, such as multiple (≥3) insertion attempts (1.4% vs 0.4%; P = 0.01) and unsuccessful initial insertion (44.1% vs 11.8%; P < .001). Furthermore, 33.1% of patients in the ETI group were reintubated after arrival to the Emergency Department. The study had several limitations, including the pragmatic and unblinded design, practice setting, and ETI performance characteristics.
This raises the question of whether ETI should be the standard for airway management. The results from this trial suggest that a strategy of initial LT insertion improved clinical outcomes and perhaps should be the preferred initial airway management strategy in OHCA. We will cover AIRWAYS-2 tomorrow, which showed no difference in outcomes using a different SGA, the i-gel.
FOAMfrat has interviews with the lead authors of PART and AIRWAYS-2.
EMLoN has a quick, incisive analysis of both the PART and AIRWAYS-2 studies.
Journal of EMS weighs in on this study.
JWatch concluded, Maybe Paramedics Should Not Perform ETI (subscription required)
Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044.
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Reviewed by Clay Smith