Effect Of A Strategy Of A Supraglottic Airway Device Vs Tracheal Intubation During Out-of-hospital Cardiac Arrest On Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial
Benger, J.R., et al, JAMA 320(8):779, August 28, 2018
SUMMARY:
Overall outcomes from out of hospital cardiac (OHCA) are poor. One point of debate in management has been airway interventions..
In observational studies looking at adult airways with more than 100,000 patients there is a suggestion that BVM is superior to intubation. We now have supraglottic airways that offer the advantage of being simpler, faster and requiring less training and practice.
The objective of this trial was to estimate the between group difference in modified Rankin Scale score at 30 days after hospital discharge from OHCA based on airway type used in the field. The trial was conducted across 4 large EMS systems in England.
Because real time randomization in the middle of a code is not feasible, they conducted a cluster randomized trial in which paramedics were the clusters (not the EMS system or base station). Paramedics were therefore randomized to and trained in either SGA (basically LMA) or ET (suggested DL with a bougie)
1523 paramedics were recruited and randomized and they treated/enrolled 9269 patients with OHCA.
Primary outcome (mRS 0-3) was achieved in 6.4% LMA vs. 6.8% ET group. Initial ventilation was successful in 87.4% of the LMA group vs. 79.0% of the ET
Interestingly, patients managed by ETI paramedics were less likely to get an advanced airway (77.6% ET vs. 85.2% in the LMA).
Airway complications like regurgitation and aspiration which were similar between groups.
Patients who had no advanced airway placed in the field did much better than those who got one with 21.1% having a good outcome compared to 3.3%.
EDITOR’S COMMENTARY: This multicenter, cluster randomized clinical trial of paramedics in England found that advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in an increased rate of favorable functional outcomes at 30 days. Importantly, this study cohort includes patients that did and did not get an advanced airway and we don’t know why. There may have also been big differences management between the groups (TTM, medications, OHCA etiology) not reported. Overall this is large RCT that suggests that although initial airway management with LMA didn’t improve good neurologic outcome after OHCA, it didn’t make it any worse and seems to be easier to use and is, likely, much faster.
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