Airway management and out-of-hospital cardiac arrest outcome in the CARES registry

doi:10.1016/j.resuscitation.2014.02.007

Resuscitation

Volume 85, Issue 5, May 2014, Pages 617-622

https://doi.org/10.1016/j.resuscitation.2014.02.007 Get rights and content

Abstract

Background

Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.

Methods

We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES). Primary exposures were ETI, SGA, or no advanced prehospital airway placed. Primary outcomes were sustained ROSC, survival to hospital admission, survival to hospital discharge, and neurologically-intact survival to hospital discharge (cerebral performance category 1–2). Propensity scores characterized the probability of receiving ETI, SGA, or no advanced airway. We adjusted for Utstein confounders. Multivariable random effects regression accounted for clustering by EMS agency. We compared outcomes between (1) ETI vs. SGA, and (2) [no advanced airway] vs. [ETI or SGA].

Results

Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC (OR 1.35; 95%CI 1.19–1.54), survival to hospital admission (1.36; 1.19–1.55), hospital survival (1.41; 1.14–1.76) and hospital discharge with good neurologic outcome (1.44; 1.10–1.88). Compared with [ETI or SGA], patients receiving no advanced airway attained higher survival to hospital admission (1.31; 1.16–1.49), hospital survival (2.96; 2.50–3.51) and hospital discharge with good neurologic outcome (4.24; 3.46–5.20).

Conclusion

In CARES, survival was higher among OHCA receiving ETI than those receiving SGA, and for patients who received no advanced airway than those receiving ETI or SGA.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health problem affecting over 300,000 persons in the United States each year.¹ Airway management is a core element of OHCA resuscitation. In the United States, 80% of OHCA resuscitations receive prehospital airway management, and the most common advanced airway intervention is endotracheal intubation (ETI).

Supraglottic airways (SGA) such as the Esophageal-Tracheal Combitube (ETC), Laryngeal Mask Airway (LMA) and King Laryngeal Tube (King LT), offer an alternative approach to advanced airway management. There is growing enthusiasm for the use of SGA insertion during OHCA resuscitation due to its simpler insertion versus ETI. Many EMS personnel choose primary SGA insertion to avoid interruptions in cardiopulmonary resuscitation chest compression continuity.2, 3 Despite the growing out-of-hospital use of SGA, there have been relatively few comparisons of OHCA outcomes between patients receiving ETI and those receiving SGA insertion.⁴ More recently, select studies have even suggested improved survival without the insertion of any advanced airway device in OHCA.⁵

The Cardiac Arrest Registry to Enhance Survival (CARES) Surveillance Group is the largest multi-site network characterizing OHCA care and outcomes in North America.⁶ In the present study, we sought to evaluate the impact of EMS airway management strategy upon outcomes after OHCA in CARES. Specifically, we compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway.

Section snippets

Study design and setting

This study was approved by the Institutional Review Boards of the University of Cincinnati and the University of Alabama at Birmingham. We conducted a secondary analysis of out-of-hospital cardiac arrest data from the Cardiac Arrest Registry to Enhance Survival (CARES) registry.

Data source

CARES is a multicenter registry of OHCA episodes from across the United States.⁷ Currently, over 400 EMS agencies from 40 communities and 10 state-based registries contribute data to CARES. These agencies serve a total

Results

During the study period there were 12,875 out-of-hospital cardiac arrests reported by CARES EMS agencies. We excluded 256 children <18 years old and 83 where age was unknown. We excluded an additional 1847 where the EMS agency did not provide airway management information. Of the remaining 10,691 adult OHCA patients, over 80% underwent successful insertion of an advanced airway device. (Table 1) Among patients receiving an advanced airway, approximately two-thirds received ETI and one-third

Discussion

Our findings in this analysis of a large, multi-center US-based registry of OHCA are similar to those published previously and provide more support to the associations between prehospital airway management choices and ultimate neurologically-intact survival. OHCA in the CARES network receiving no advanced airway exhibited superior outcomes than those receiving ETI or SGA. When an advanced airway was used, ETI was associated with improved outcomes compared to SGA.

Many EMS practitioners consider

Conclusion

In the CARES network, survival was higher among OHCA receiving ETI than those receiving SGA. Survival was markedly higher among patients who received no advanced airway than those receiving endotracheal intubation or supraglottic airway placement.

Conflict of interest statement

All authors have no conflicts of interest to report.

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Cited by (138)

Supraglottic airway devices are associated with asphyxial physiology after prolonged CPR in patients with refractory Out-of-Hospital cardiac arrest presenting for extracorporeal cardiopulmonary resuscitation
2023, Resuscitation
Multiple randomized clinical trials have compared specific airway management strategies during ACLS with conflicting results. However, patients with refractory cardiac arrest died in almost all cases without the availability of extracorporeal cardiopulmonary resuscitation (ECPR). Our aim was to determine if endotracheal intubation (ETI) was associated with improved outcomes compared to supraglottic airways (SGA) in patients with refractory cardiac arrest presenting for ECPR.
We retrospectively studied 420 consecutive adult patients with refractory out-of-hospital cardiac arrest due to shockable presenting rhythms presenting to the University of Minnesota ECPR program. We compared outcomes between patients receiving ETI (n = 179) and SGA (n = 204). The primary outcome was the pre-cannulation arterial PaO₂ upon arrival to the ECMO cannulation center. Secondary outcomes included neurologically favorable survival to hospital discharge and eligibility for VA-ECMO based upon resuscitation continuation criteria applied upon arrival to the ECMO cannulation center.
Patients receiving ETI had significantly higher median PaO₂ (71 vs. 58 mmHg, p = 0.001), lower median PaCO₂ (55 vs. 75 mmHg, p < 0.001), and higher median pH (7.03 vs. 6.93, p < 0.001) compared to those receiving SGA. Patients receiving ETI were also significantly more likely to meet VA-ECMO eligibility criteria (85% vs. 74%, p = 0.008). Of patients eligible for VA-ECMO, patients receiving ETI had significantly higher neurologically favorable survival compared to SGA (42% vs. 29%, p = 0.02).
ETI was associated with improved oxygenation and ventilation after prolonged CPR. This resulted in increased rate of candidacy for ECPR and increased neurologically favorable survival to discharge with ETI compared to SGA.
Demographic disparities in tracheal intubation success rates during infant out-of-hospital cardiac arrest
2023, Trends in Anaesthesia and Critical Care
Citation Excerpt :
It is worth noting there is ongoing controversy as to the preferred strategy for airway management in cardiac arrest in both adult and pediatric patients [29,30]. Results from a number of studies have shown conflicting results as to whether tracheal intubation is associated with improved outcomes [8,9,31–37]. The aim of our study is not to make a claim that tracheal intubation ought to be the preferred cardiac arrest airway strategy.
Tracheal intubation is a skill performed by qualified emergency medical services (EMS) providers during out-of-hospital cardiac arrest (OHCA) in adult and pediatric patients. Unsuccessful intubation can negatively impact a patient's likelihood of survival. Thus, intubation success rates are an important quality improvement benchmark. Given other demographic disparities that have been reported in adults and children, we hypothesize there might be disparities in intubation success across infant race/ethnicity and/or sex.
We examined a national-level registry of EMS activations in the United States (NEMSIS). Inclusion criteria were OHCA calls involving infant patients (under 1 years of age) between January 2017 and May 2022 where EMS attempted tracheal intubation, documented whether the procedure was successful, and documented information about the patient's demographics (eg. race/ethnicity and sex). Intubation success rates across patient sex and racial/ethnic categories with more than one-hundred cardiac arrests with intubation attempts were compared.
A total of 3663 infant cardiac arrests where tracheal intubation was attempted met inclusion criteria. White infants were associated with significantly higher rates of intubation success (62.2%) when compared with Black or African American infants (58.1%) and Hispanic/Latino infants (56.2%) (p < .01). Female infants were associated with slightly higher rates of intubation success than male infants, but this difference was not significant (p > .2).
Significant demographic disparities in endotracheal intubation success rates exist among infants who experience OHCA. Future studies should continue to examine these disparities with the goal of identifying why these differences occur and concrete mechanisms for eliminating such disparities.
A novel scoring system using easily assessible predictors of return of spontaneous circulation and mortality in traumatic out-of-hospital cardiac arrest patients: A retrospective cohort study
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An accident event may necessitate triage of multiple cases of traumatic out-of-hospital cardiac arrest (TOHCA). However, factors for prioritizing treatment among multiple TOHCA patients have not been established. This study aims to use easily assessible predictors of TOHCA outcomes to develop a triage scoring system.
Patients with TOHCA brought to our hospital by emergency medical services (EMS) were included for analysis to identify independent risk factors for poor outcomes. A scoring system was developed and validated internally and externally.
Of the 401 included patients, 86 (21.4%) had return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) for 30 min (81 patients, 94.2%) or 45 min (86 patients, 100%). The emergency department (ED) mortality rate was 89.3% and overall in-hospital mortality rate was 99%. Univariate and multivariate analyses identified body temperature <33 °C (OR, 4.65; 95% CI, 1.37–15.86), obvious chest injury (OR, 2.11; 95% CI, 1.03–4.34), and presumable etiology of out-of-hospital cardiac arrest (OR, 1.73; 95% CI, 1.01–2.98) as significant independent risk factors for non-ROSC. The TOHCA score, calculated as 1 point per risk factor, correlated significantly with the rate of non-ROSC and ED mortality (TOHCA score 0, 1, 2, 3: non-ROSC rate, 63.0%, 80.4%, 90.8%, 100%, respectively; ED mortality rate, 79.5%, 91.5%, 96.1%, and 100% respectively). The results of internal and external validations show a similar trend in both non-ROSC and mortality in the ED with increasing score.
Termination of CPR for TOHCA after 45 min is reasonable; a 30-min resuscitation is acceptable in case of insufficient medical staff or resources. The TOHCA score may be able to be used with caution for triage.
Success of prehospital tracheal intubation during cardiac arrest varies based on race/ethnicity and sex
2022, Trends in Anaesthesia and Critical Care
Tracheal intubation is a high-risk procedure often performed in the prehospital setting by emergency medical services (EMS) on patients experiencing cardiac arrest. Because of the high potential for adverse consequences resulting from unsuccessful intubation, intubation success rates are a topic of significant concern. There has been little research examining whether cardiac arrest intubation success rates vary based on patient race/ethnicity and patient sex.
We examined a national registry of EMS calls in the United States. Inclusion criteria were tracheal intubations (2017–2021) performed on adult cardiac arrest patients where EMS providers documented the patient's race/ethnicity and patient sex and whether the intubation was successful. A total of 210,992 cardiac arrests met inclusion criteria. When considering patient sex, intubation was more common in male patients than female patients, but intubation success rates were significantly higher in female patients (p < .01). When considering patient race/ethnicity, intubation success rates were highest in White patients and significantly lower in patients of all other races/ethnicities (p < .01).
Intubation success rates were higher in female patients and White patients. Further studies need to examine disparities and identify strategies to improve intubation success for all patients with cardiac arrest. Possible explanations for the obtained results are differences in patient health, in provider familiarity with intubation, and in the availability of assistive technologies that facilitate intubation (e.g. video laryngoscopy).
Outcome of cardiopulmonary resuscitation with different ventilation modes in adults: A meta-analysis
2022, American Journal of Emergency Medicine
The optimal airway management strategy for cardiac arrest remains unclear. This study aimed to compare the effects of different initial airway interventions on improving clinical outcomes based on the 2010 cardiopulmonary resuscitation (CPR) guidelines and later.
We searched PubMed, EMBASE, and the Cochrane Library for CPR articles tailored to each database from October 19, 2010, to July 31, 2021, to compare endotracheal intubation (ETI), supraglottic airway (SGA), or bag-valve-mask ventilation (BMV). The initial results and long-term results were investigated by meta-analysis.
Twenty-five articles (n = 196,486) were included. The ROSC rate in the ETI group (ES = 0.49, 95% CI: 0.38–0.59) was significantly higher than that in the SGA group (ES = 0.27, 95% CI: 0.20–0.34) and BMV group (ES = 0.24, 95% CI: 0.17–0.31). The rate of ROSC upon admission to the hospital in the ETI group (ES = 0.27, 95% CI: 0.13–0.42) was significantly higher than that in the SGA group (ES = 0.18, 95% CI: 0.13–0.23) and BMV group (ES = 0.16, 95% CI: 0.10–0.22). Compared with the BMV group (ES = 0.09, 95% CI: 0.04–0.14) and the SGA group (ES = 0.08, 95% CI: 0.05–0.10), the ETI group (ES = 0.14, 95% CI: 0.10–0.17) had a higher discharge rate, but all of the groups had the same neurological outcome (ETI group [ES = 0.06, 95% CI: 0.04–0.08], BMV group [ES = 0.05, 95% CI: 0.03–0.08] and SGA group [ES = 0.04, 95% CI: 0.03–0.05]).
Opening the airway is significantly associated with improved clinical outcomes, and the findings suggest that effective ETI based on mask ventilation should be implemented as early as possible once the patient has experienced cardiac arrest.
Impact of different medical direction policies on prehospital advanced airway management for out-of hospital cardiac arrest patients: A retrospective cohort study
2022, Resuscitation Plus
Although optimal prehospital airway management after out-of-hospital cardiac arrest (OHCA) remains undetermined, no studies have compared different advanced airway management (AAM) policies adopted by two hospitals in charge of online medical direction by emergency physicians. We examined the impact of two different AAM policies on OHCA patient survival.
This observational cohort study included adult OHCA patients treated in Okayama City from 2013 to 2016. Patients were divided into two groups: the O group - those treated on odd days when a hospital with a policy favoring laryngeal tube ventilation (LT) supervised, and the E group - those treated on even days when the other hospital with a policy favoring endotracheal intubation (ETI) supervised. Multiple logistic regression analysis was performed to assess airway device effects. The primary outcome measure was seven-day survival.
Of 2,406 eligible patients, 50.1% were in the O group and 49.9% were in the E group. O group patients received less ETI (1.0% vs. 12.0%) and more LT (53.3% vs. 43.0%) compared with E group patients. In univariate analysis, no differences were observed in seven-day survival (9.4% vs 10.1%). Multiple regression analysis revealed neither LT nor ETI had a significant independent effect on seven-day survival, considering bag-valve mask ventilation as a reference (OR, 0.78; 95% CI, 0.54 to 1.13, OR, 0.79; 95% CI, 0.36 to 1.72, respectively).
Despite different advanced airway medical direction policies in a single city, there were no substantial impact on outcomes for OHCA patients.

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^☆: 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.2014.02.007.

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Clinical paperAirway management and out-of-hospital cardiac arrest outcome in the CARES registry☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design and setting

Data source

Results

Discussion

Conclusion

Conflict of interest statement

Resuscitation

Ann Emerg Med

Resuscitation

Resuscitation

Ann Emerg Med

Heart disease and stroke statistics—2013 update: a report from the American Heart Association

Circulation

Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation

Circulation

Clinical paper
Airway management and out-of-hospital cardiac arrest outcome in the CARES registry☆