“EMS personnel and physicians involved with protocol development for EMS systems in the United States, United Kingdom, and similar settings with limited exposure to advanced airway management should reconsider the routine use of endotracheal intubation as the first-line strategy for airway management in out-of-hospital cardiac arrest.”
This is the conclusion of an editorial in the August 28, 2018 edition of the Journal of the American Medical Association.
The editorial, “Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest,” is in response to two major new prehospital randomized, controlled airway studies published in the same edition of the journal.
In the first study, the Pragmatic Airway Resuscitation Trial (PART), researchers found initial insertion of a laryngeal tube (King-LT) in victims of cardiac arrest “was associated with a significantly greater 72-hour survival compared with a strategy of initial endotracheal intubation.” The authors found that a King LT Airway outperformed the endotracheal intubation in every category in which they compared, including a 2.7% better increase in survival to hospital discharge, which would translate into 10,000 additional lives saved nationwide.
The second study, AIRWAYS-2, did not find a statistical difference between using a supraglottic airway (igel) and endotracheal intubation. These were both high quality studies conducted at many sites in the United States (PART) and Great Britain (AIRWAYS-2).
The Pragmatic Airway Resuscitation Study (PART) enrolled over 3000 patients and was conducted by 27 different EMS services in 5 metropolitan areas over the course of two years.
You can read the studies and editorial here.
Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest
JEMS has an analysis of the study here:
ETI vs. SGA: The Verdict Is In
There have been many other analyses of the studies on medical sites.
The Great Prehospital Airway Debate
EM Nerd-The Case of the Needless Imperative
What does this mean?
Here in Connecticut, we no longer consider the endotracheal tube as the gold standard for airway management. Supraglottic airways can be either the primary or backup airway based on the circumstances of each call.
Additionally, ET is limited to three attempts.
Before we went to statewide protocols, our regional guidelines limited ET attempts to two by the first medic, and one additional attempt if another medic is present and wants to try.
That works for me.
I am not ready to give up on ET intubation. It remains my preferred method, but I do not hesitate to drop a combitube from the get go if I am presented with a patient who I suspect based on their anatomy or where they lay, will be a difficult tube. I once immediately dropped on combitube in an obese patient in a hospital bed that was shoved into the corner of a room in a horder’s house. Fifteen seconds later, I had an airway. If I had gone for an ET, I wouldn’t have even had my ET roll unzipped, and the tube and stylet and syringe unwrapped from their sterile packaging, much less having to move the bed and patient and all the crap in the house that would interfere with that.
If a medical director told me that based on his reading of the literature and his worry that the risk of ET intubation in the hands of unskilled medics was too great and that we should remove ET intubation altogether, I would understand and would have a hard time protesting too loud.
Remember: The important airway goals are safely securing the airway in a timely fashion, avoiding interruptions in chest compressions, and limiting attempts. In cardiac arrest, the only two interventions proven to improve mortality are quality chest compressions and timely defibrillation.
