Date: February 26th, 2019

Reference: Benger et al. 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. JAMA 2018

Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a physician assistant practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program.

Case: EMS arrive to your emergency department with a 68-year-old man post cardiac arrest patient.  They had a difficult time getting a definitive airway pre-hospital. It required multiple attempts which caused several prolonged interruptions in CPR. After the patient is stabilized the medic asks you how he can improve his airway management skills during a cardiac arrest as it was difficult to intubate during compressions. What should you tell him?

Background: We have covered OHCA many times on the SGEM. Key to survival is high-quality CPR and early defibrillation. There is no evidence for a patient-oriented benefit with epinephrine (SGEM#238), other ACLS drugs (SGEM#64), pre-hospital therapeutic hypothermia (SGEM#54, SGEM#183), or mechanical CPR (SGEM#136). One issue we have not discussed is endotracheal intubation.

For many years endotracheal intubation has been the standard of care for airway management in out-of-hospital cardiac arrest (OHCA). Over recent years this practice has been questioned. Endotracheal intubation is a technical skill requiring optimal positioning, proficiency and a technical skill level which may be difficult to obtain in the pre-hospital cardiac arrest setting.

Clinical Question #1: Are superglottic airway devices non-inferior to endotracheal intubation in OHCA with regards to neurologic outcome?

Reference: Benger et al, 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. JAMA 2018

* Population: Adults who had a non-traumatic OCHA.

* Exclusions: Prisoners, resuscitation deemed inappropriate, advanced airway already in place, and patient’s mouth opened less than 2cm.

* Intervention: The intervention was the insertion of a second-generation supraglottic airway (SGA) device with a soft non-inflatable cuff (i-gel; Intersurgical).

* Comparison: Endotracheal tube intubation (ETI) with direct laryngoscopy

* Outcomes:

* Primary Outcome: Neurologic outcome at discharge or 30 days using the modified Rankin Scale (mRS score 0-3 = good outcome and mRS score 4-6 = bad outcome).

* Secondary Outcomes: Initial ventilation success, which was defined as visualizing chest rise. Regurgitation (stomach contents visible in the mouth or nose) or aspiration (stomach contents visible below the vocal cords or inside a correctly placed tracheal tube or airway channel of a SGA device). Any unintended loss of a previously established airway. Sequence of airway interventions delivered. Return of spontaneous circulation (ROSC). Airway management in place when ROSC was achieved, or resuscitation was discontinued. Chest compression fraction. Time to death

Authors’ Conclusions: “Among patients with out-of-hospital cardiac arre...