Draft ILCOR Advanced Airway Recommendations: Banning Paramedic Intubation-What System will be the First?

 

The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR), the group that forms the basis for the AHA ACLS guidelines, has released a new draft guideline on Advanced Airway Management During Adult Cardiac Arrest.  The guideline is available for public comment until April 2, 2019.

Advanced Airway Management During Adult Cardiac Arrest

The recommended guideline takes into account the latest literature, including The Pragmatic and AIRWAYS-2 trials:

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

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

Here areILCOR's the key draft recommendations:

Treatment Recommendations

• We suggest using bag-mask ventilation or an advanced airway strategy during CPR for adult cardiac arrest in any setting .
• If an advanced airway is used, we suggest a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success.
• If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate.

While they do not specifically define what low versus high intubation rates are, they write the following:

We have not provided a precise value or range of values for low and high intubation success rate, nor an agreed definition. Studies have used different definitions of tracheal intubation success. Using the individual study definitions, we considered the Wang and Benger RCTs (Benger 2018 779, Wang 2018 769) as having a low tracheal intubation success rate (51.6% and 69.8% respectively) and the Jabre study (Jabre 2018 779) as having a high success rate (97.9%).

In other words, if your service has an intubation success rate of 69.8% or less, then you are should be using a supraglottic airway instead of tracheal intubation.

(Intubation success should not judged on whether or not the patient eventually comes in with an ET tube place (after multiple attempts), but your rate per attempted laryngoscopy.)

When I began as a medic in 1993, ET was the standard for prehospital care.  We did not even carry supraglottic (backup) airways.  Today supraglottic airways, and even bag value mask, are considered acceptable alternatives.   As research continues to show that tracheal intubation does not lead to improved outcomes and may lead to worse, medical directors are going to start pulling intubation from their medics’s arsenal.  To date, I am not aware of any who have done so.  What system will be the first?