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Article Bites: Significance of attempts in airway management

The negative association between number of airway attempts and neuro-intact survival following OHCA

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Article Summary by Casey Patrick, @cpatrick_89

Article reviewed: Murphy, D. L., Bulger, N. E., Harrington, B. M., Skerchak, J. A., Counts, C. R., Latimer, A. J., ... & Sayre, M. R. (2021). Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest. Resuscitation, 167, 289-296.

Who, what, when, where and how?

  • Who? – 1,205 non-trauma OHCA patients with an endotracheal intubation attempt, defined as “the introduction of a laryngoscope past the teeth and concluded when the laryngoscope was removed from the mouth, regardless of whether or not an endotracheal tube was inserted.”
  • What? – Retrospective, observational, cohort (cohort = OHCA/intubation)
  • When? – January 2015 – June 2019
  • Where? – Seattle Fire
  • How? – Primary outcome = neuro intact survival (CPC1/2)
  • Excluded no attempt, BLS only, intubated after ROSC, DNR, other services
Screen Shot 2022-06-29 at 10.06.48 AM.png

Figure/courtesy Maia Dorsett, MD, PhD, FAEMS


  • Age = 60s, 68% male, 33% witnessed, 61% received bystander CPR, 21% shockable rhythm
  • ROSC 44%, Hospital admission 38%, Survival to d/c 11%
  • First attempt success 65%, second 86%
  • Overall rate of supraglottic use – 2.8%, 0.7% after 2 attempts, 11.2% after 3 attempts, 28.4% after 4+ attempts
  • Primary outcome = CPC 1/2
    • There was a negative correlation between number of ET attempts and neurologically intact outcome: 11% CPC 1/2 with ONE intubation attempt, 4% with two, 3% with three and 2% with four-plus (see Figure)
    • These differences held for shockable vs. non-shockable rhythms
    • Multivariable stats modeling adjusted for: age/sex/witness/bystander/times/initial rhythm


Read more:

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The questions

  • What about SGAs? This isn’t a rehash of PART/AIRWAYS-2. Overall rate of SGA use was very low.
  • Mean time to airway = 5 minutes in this study
  • Yes, this is retrospective but ... very granular (especially in OHCA world)
  • Incorporated monitor data PLUS audio (1,200 patients!)

What should we do now?

  • No, this doesn’t translate directly to agencies using “primary SGA” in OHCA
  • But, more evidence airway delays = worsened patient-oriented outcome
    • Should there be a more rapid transition to SGA use after failed primary intubation attempt?

The bottom line: Concentrate on the interventions that we know matter: Early recognition and bystander CPR, access to early defibrillation, minimize pauses, proper compression rate and depth.

Edited by EMS MEd Editor Maia Dorsett, MD, PhD, FAEMS (@maiadorsett)

The National Association of EMS Physicians (NAEMSP) is an organization of physicians and other professionals partnering to provide leadership and foster excellence in the subspecialty of EMS medicine. The NAEMSP promotes meetings, publications and products that connect, serve and educate its members, and acts as an advocate of EMS-related decisions in cooperation with organizations throughout the country.