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Prehospital Cardiac Arrest – Is Advanced Airway or BVM Best?

March 8, 2022

Written by Aaron Lacy

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Endotracheal tube (ETT) or supraglottic airway (SGA) vs bag-valve mask (BVM) airway management in prehospital cardiac arrest made no difference in neurologically favorable survival at 30-days when controlled for clinical differences.

Why does this matter?
The chain of survival begins with the call to 911, with lasting impacts with each step in management. One of the key early links in this chain is EMS care, in particular, airway management by them. Prehospital airway management has been studied in the literature and covered on JournalFeed extensively but with mixed results. Where does this study fit into the current landscape, and what does it mean for you?

Just in case the water wasn’t murky enough…

This paper

  • This was a retrospective review of 9,616 adult cardiac arrests of medical etiology (i.e. non trauma/burn) from a Korean database.
  • After controlling for clinical differences in three separate ways (propensity score matching (PSM), inverse probability of treatment weight (IPTW), and LASSO), there was no difference between advanced airway management (AAM = ETT or SGA; n = 6,232; 5,410; and 822, respectively) and BVM (n=3,354) on neurological favorable survival at 30 days (PSM 9.6% vs 10.0%; HR=0.98, 95% CI=0.93 to 1.03, p >0.05).
  • A subgroup analysis comparing ETT-alone vs BVM and SGA-alone vs BVM showed improved 30-day neurologically favorable survival with ETT placement (IPTW 0.88, 95% CI 0.78 to 0.98, p = 0.023) but not SGA management (IPTW 1.00, 95% CI 0.95 to 1.05, p = 0.99) compared to BVM.
  • Another subgroup analysis showed more favorable neurological outcome with ETT over SGA management (p = 0.005).

Prior Literature

  • There are studies showing worse, equivocal, and better outcomes comparing BVM to other management in out-of-hospital cardiac arrest, with this one being equivocal.
  • There are studies showing worse, equivocal, and better outcomes comparing SGA placement to other management in out-of-hospital cardiac arrest, with this one being equivocal.
  • There are studies showing worse, equivocal, and better outcomes comparing ETT vs other management in out-of-hospital cardiac arrest, with this one showing improvement.
  • These are 9 separate papers and conclusions out of a litany of research on the topic. The point is, this subject is murky.

What can we take away from this study?

  • The authors of this paper acknowledge that even in their own database over time there have been differences in outcomes comparing different airway management strategies.
  • This study is unique because it worked diligently to correct for clinical differences between patients.
  • In the end, most of the higher quality literature supports that a SGA or BVM technique is equivocal or better than ETT during out-of-hospital cardiac arrest. Placement of an ETT in out-of-hospital cardiac arrest should be done by those with adequate training and with equipment that will maximize success in select circumstances. Defining those specific circumstances is the difficult part.

Source
Prehospital airway management for out-of-hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry. Acad Emerg Med. 2022 Jan 22. doi: 10.1111/acem.14443. Online ahead of print.

What are your thoughts?