Written by Seth Walsh-Blakemore
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In pediatric out-of-hospital cardiac arrest (OHCA), patients managed by emergency physicians in a mobile ICU who had endotracheal intubation (ETI) were found to have lower odds of survival at 30 days when compared to bag valve masking (BVM) or supraglottic airway (SGA).
Why does this matter?
PALS emphasizes correction of hypoxia and is equivocal in its recommendation for airway management. A large in-hospital arrest registry study published in JAMA 2016 found improved survival to discharge with bag-mask ventilation vs ETI or SGA. A nationwide registry in Japan had similar findings, as did a meta-analysis in 2019. These studies were limited by heterogeneity in provider experience. Would these outcomes and recommendations change if an emergency physician was there to manage the airway in OHCA?
Not worth the wait to intubate?
This was a retrospective, multi-center cohort of 1,579 children obtained from the French National OHCA registry from 2011-2018. These patients were all managed by a mobile ICU consisting of a driver, nurse, and emergency physician, as is common in the French EMS system. Patients were propensity scored and weighted using inverse probability of treatment matching. This method is essentially a simulation of matched random treatment assignment for observational studies. The primary outcome was 30-day survival. 85.8% of patients received ETI. Of the patients not receiving ETI, 92.9% received BMV; 7.1% SGA. 30-day survival was 7.7% in the ETI group vs 14.2% in the non-ETI group (absolute difference 6.6%, 95%CI 2.3-12.0). 30-day survival had a propensity adjusted OR of 0.39 (95%CI 0.25-0.62) for the ETI group and 0.32 (95%CI 0.19–0.54) for good neurological outcome. There was no significant difference in ROSC (paOR, 1.15; 95% CI, 0.80–1.65; p = 0.46).
A mobile ICU isn’t generalizable to most EMS services in our communities, but even with optimal EMS resources and physician expertise, the evidence does not support diverting time and personnel towards an advanced airway strategy in children with OHCA. This is in line with prior studies, and despite our perceived expertise, we shouldn’t always feel the need to secure the airway before transporting to the hospital. Of course, consider the broader context – such as long-term airway security for those with prolonged transport times or interfacility transfers. But for OHCA, it’s probably best to get ROSC and do the intubation later.
Edited by Aaron Lacy and Clay Smith
Source
Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study. Resuscitation. 2021 Aug 18;S0300-9572(21)00314-2. doi: 10.1016/j.resuscitation.2021.08.015. Online ahead of print.
I agree with "But for OHCA, it’s probably best to get ROSC and do the intubation later". I haven’t read this paper, but I bet the problem with this study is the same as all the other ETI observational studies: did they properly account for illness severity? Even fancy propensity score matching wont get you out of this problem if you don’t have a proper pre-hospital measured severity score which there aren’t at this time.