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ETT vs. SGA for OHCA – Metaanalysis Includes AIRWAYS-2 and PART

January 21, 2019

Written by Clay Smith

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There was no difference in an endotracheal tube (ETT) vs supraglottic airway (SGA) for patients with out-of-hospital cardiac arrest (OHCA) in the outcomes of return of spontaneous circulation (ROSC), survival to admission, survival to discharge, or survival with good neurological outcome in studies with low risk of bias in this large metaanalysis.

Why does this matter?
AIRWAYS-2 and PART were large RCTs we recently covered regarding OHCA and whether an ETT or SGA was better. AIRWAYS-2 (using an i-gel) found no difference in discharge with good neurological outcome. PART found the SGA (a King laryngeal tube) improved 72-hour survival, return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurologic outcome. Here is a look at a large number of studies on this same topic.

I’m leaning toward the SGAs
This was an enormous metaanalysis of 29 studies (including the recent AIRWAYS-2 and PART RCTs) – 539,146 patients – to determine which was better during arrest: an ETT or SGA. For ROSC and survival to hospital admission, there appeared to be an advantage to ETT over SGA (ROSC OR = 1.44). However, there was significant heterogeneity in the studies included, overall low quality of evidence, and a high risk of bias. When only the studies with low risk of bias were included (i.e. RCTs), the beneficial effect of ETT over SGA was no longer seen (ROSC = 0.92; 95%CI 0.80 to 1.05). There was only one subgroup that might have had improved ROSC and survival to admission with ETT over SGA, namely patients receiving automated chest compressions (ROSC OR = 1.55; 95%CI 1.20 to 2.00). For the outcomes of survival to discharge and survival to discharge with neurologically intact state, there was no difference in outcome with ETT vs SGA in studies with low risk of bias (OR 0.9 and 0.88, respectively – not significant). Again, the overall quality of evidence was low and at high risk of bias.

It doesn’t appear to make a difference which airway management strategy is used. But based on the apparent preference for SGAs over ETTs in both AIRWAYS-2 and PART by prehospital personnel and the favorable findings in PART, I conclude that a SGA is probably best. It is simpler to place and gives equal or better outcome to an ETT. Also, it is very difficult to acquire and maintain intubation skills, and most prehospital personnel don’t intubate often, maybe once or twice each year. Skill decay is a real problem. Intubating during arrest is even more difficult and takes even more time and training to master.

Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis. Am J Emerg Med. 2018 Dec;36(12):2298-2306. doi: 10.1016/j.ajem.2018.09.045. Epub 2018 Sep 26.

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What are your thoughts?