Timing of Airway Management in OHCA – Does It Matter?

May 30, 2024

Written by Aaron Lacy

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In a large retrospective review of patients with out-of-hospital-cardiac-arrest (OHCA) there was a very small, and probably clinically insignificant, association with favorable neurological outcome and survival in those who underwent early as opposed to late advanced airway management. 

ABC, BAC, CBA? When to do the airway?
This study found a statistically significant difference in favorable neurologic outcome (Risk ratio 0.997, 95%CI 0.995-0.999) and 1-month survival (RR 0.990, 95%CI 0.986-0.994) when comparing early (<10 minutes) to late (>10 minutes) advanced airway management (ETI, SGA) in OHCA patients. 21,446 patients were included in the early advanced airway management group, with 19,655 in the late category.

While other studies have looked at timing and type of advanced airways in OHCA patients, this study is unique as they did an exceptional job focusing on reducing resuscitation time bias (the idea that those who are down longer get more intervention, introducing bias). While they found statistically significant differences in their planned primary and secondary analysis, they correctly point out that the differences are so small it is unlikely to be clinically significant. This is consistent with other studies which have looked at timing of intubation in cardiac arrest.

How will this change my practice?
Every situation is unique, so it is difficult to make blanket recommendations. However, I favor advising placement of a supraglottic airway when most feasible in the prehospital setting when managing OHCA, so the focus can be on other more proven interventions (high quality CPR, early defibrillation, etc.). This is consistent with recent prehospital airway management guidelines. This article supports my current practice, so is unlikely to change my opinions unless new evidence comes to light.  

Source
Early versus late advanced airway management for adult patients with out-of-hospital cardiac arrest: A time-dependent propensity score matched analysis. Acad Emerg Med. 2024 Apr 8. Epub ahead of print. DOI: 10.111/acem.14907