Resuscitation 83 (2012) 1061–1066 Contents lists available at SciVerse ScienceDirect Resuscitation jo urnal homepage: www.elsevier.com/locate/resuscitation Clinical paper Endotracheal intubation versus supraglottic airway insertion in out-of-hospital ଝ cardiac arrest a,∗ b c d,e f Henry E. Wang , Daniel Szydlo , John A. Stouffer , Steve Lin , Jestin N. Carlson , g b e h Christian Vaillancourt , Gena Sears , Richard P. Verbeek , Raymond Fowler , h i j k Ahamed H. Idris , Karl Koenig , James Christenson , Anushirvan Minokadeh , l m,n Joseph Brandt , Thomas Rea , The ROC Investigators a Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, United States b The Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, United States c Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States d Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada e Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada f Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States g Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada h Department of Surgery, University of Texas Southwestern Medical Center Dallas, Dallas, TX, United States i Clackamas County Fire District #1, Portland, OR, United States j Department of Emergency Medicine, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada k Department of Anesthesiology, University of California San Diego, San Diego, CA, United States l Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States m Department of Medicine, University of Washington, Seattle, WA, United States n Emergency Medical Services Division, Public Health Seattle, Seattle, WA, United States a r t i c l e i n f o a b s t r a c t Article history: Objective: To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest com- Received 1 March 2012 pression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway Received in revised form 14 May 2012 (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital Accepted 21 May 2012 cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA. Methods: We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Con- Keywords: sortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion Cardiopulmonary arrest (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome Intubation (intratracheal) was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Sec- Emergency medical services ondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out- of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders. Results: Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16). Conclusions: In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA. © 2012 Elsevier Ireland Ltd. All rights reserved. ଝ A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.05.018. ∗ Corresponding author at: Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th Street South, OHB 251, Birmingham, AL 35249, United States. Tel.: +1 205 996 6526; fax: +1 205 975 4662. E-mail address: [email protected] (H.E. Wang). 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2012.05.018 1062 H.E. Wang et al. / Resuscitation 83 (2012) 1061–1066 1. Introduction ROC network includes over 264 emergency medical services (EMS) 12,13,16 agencies, of which 150 participated in the PRIMED trial. Airway management is one of the most common and promi- The interventions of the ROC PRIMED trial included: (1) a com- nent interventions in the treatment of out-of-hospital cardiac arrest parison of early (immediate) versus delayed (3 min) initial ECG 12,13 (OHCA). In North America, endotracheal intubation (ETI) is the analysis; and (2) a comparison of active ITD with sham device. most common form of advanced airway management in OHCA. Both studies were stopped for futility at interim analysis, revealing Paramedics in North America have performed out-of-hospital ETI no difference in outcomes between treatment arms. The detailed 1 for over 25 years. Despite the widespread practice of out-of- methods and results of these trials have been published previously. hospital ETI, numerous studies highlight errors and adverse events associated with the intervention, including unrecognized tube mis- 2.3. Selection of participants – inclusion and exclusion criteria placement or dislodgement, multiple intubation attempts, and 2–5 iatrogenic hypoxia and bradycardia. Paramedic ETI efforts may For this analysis we included adult (≥18 years of age), treated, also adversely impact other essential components of resuscitation; non-traumatic OHCA enrolled in the ROC PRIMED study and receiv- for example, a prior study found that paramedic ETI was associ- ing successful out-of-hospital advanced airway attempts, including ated with over 90 s of cardiopulmonary resuscitation (CPR) chest efforts to perform ETI or SGA insertion. SGA devices used by ROC 6 compression interruptions. agencies included King LT, Combitube and LMA. We excluded An emerging OHCA resuscitation strategy is the use of supra- patients not receiving successful advanced airway insertion efforts. 7,8 glottic airways (SGAs) instead of ETI. SGAs commonly used We also excluded patient not requiring any advanced airway inser- by North American EMS practitioners include the King Laryngeal tion efforts. Because they did not use any SGA devices during the Tube (King LT – King Systems, Noblesville, Indiana), Combitube study period, we excluded data from Seattle/King County EMS Esophageal/Tracheal Double-Lumen Airway (Combitube – Covi- units. dien, Inc., Boulder, Colorado), and the Laryngeal Mask Airway (LMA At the time of the PRIMED study, only advanced life support – LMA North America, San Diego, California). While traditionally providers performed ETI and/or SGA insertion at the majority of used as a rescue airway in the event of failed ETI efforts, SGA ROC sites. Selection of ETI or SGA was at paramedic discretion and insertion has gained favor among EMS practitioners because of its was not dictated by written clinical protocol. The ROC PRIMED stud- simpler technique and fewer CPR chest compression interruptions ies, as well as other ROC protocols did not dictate the parameters 9–11 than ETI. Despite the broadening use of this strategy in North for SGA selection or insertion. America, there have been few evaluations of outcomes after SGA At the Ottawa site, three EMS agencies permitted basic life sup- insertion in OHCA. port personnel to perform King LT insertion. At the San Diego site, The Resuscitation Outcomes Consortium (ROC) Prehospital while basic life support rescuers were permitted to perform King Resuscitation using an Impedance valve and an Early vs. Delayed LT insertion, advanced life support EMS units arrived first for the analysis (PRIMED) study was one of the largest prospective out-of- majority of OHCA. hospital controlled trials ever performed, testing the effects of two strategies of ECG analysis and the impedance threshold device (ITD) 2.4. Methods of measurement 12,13 upon outcomes after OHCA. While not dictated by trial proto- col, EMS agencies used both ETI and SGA for airway management. All ROC sites followed uniform data collection methods con- 15,17 The objective of our current study was to compare the outcomes of sistent with Utstein standards. EMS personnel described the patients receiving ETI with those receiving SGA after OHCA in the details of clinical care on written or electronic patient care reports, ROC PRIMED trial. including information regarding the airway insertion efforts and outcomes. Each regional center determined hospital outcomes and complications through review of hospital and death records. 2. Materials and methods 2.5. Outcomes and covariates 2.1. Study design The primary outcome of this analysis was survival to hospital This study was a secondary analysis of prospectively collected discharge with satisfactory functional status, defined as a Modi- clinical trial data from the