Advanced Airway For Non-Shockable OHCA?

April 8, 2019

Written by Clay Smith

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Advanced airway management (AAM) was associated with increased overall survival in out-of-hospital cardiac arrest (OHCA) (though not survival with favorable neurological outcome) in patients with non-shockable initial rhythm. There was no difference in survival with use of AAM in patients with initial shockable rhythm.

Why does this matter?
A key study in JAMA showed bag mask ventilation was as good as endotracheal intubation (ETI) in arrest. AAM for cardiac arrest patients includes both supraglottic airways (SGA) as well as ETI.

Putting a finer point on advanced airway management in arrest
This was a national Japanese arrest registry that included over 300,000 patients with OHCA. They used a sophisticated time-dependent propensity score and sequential matching. In other words, “Patients who received AAM during cardiopulmonary resuscitation were sequentially matched with patients at risk of AAM within the same minute on the basis of time dependent propensity scores.” It took an entire page of text to describe this. Suffice it to say, they matched cohorts of patients with AAM with patients who were otherwise similar except for AAM and looked at the outcomes. They found that in patients with a non-shockable rhythm, patients with AAM had better overall survival: 2.3% vs 1.8%, adjusted risk ratio 1.27 (95% 1.20 to 1.35); yet survival with favorable neurological outcome was no different, both 0.4%. In patients with shockable rhythm, there was no difference between AAM and those without: 19.2% vs 18.6%, adjusted risk ratio 1.00 (95% CI 0.93 to 1.07). This puts a finer point on the JAMA study. There may be a subset of patients, namely non-shockable rhythm, who may benefit from AAM. However, it is still a concern that there was no change in neurologically intact survival regardless.

Source
Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study. BMJ. 2019 Feb 28;364:l430. doi: 10.1136/bmj.l430.

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Reviewed by Thomas Davis