Article Bites: Significance of attempts in airway management
The negative association between number of airway attempts and neuro-intact survival following OHCA
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
- 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
Training Day: How EMTs should be using capnography
Application of an EtCO2 sampling device and waveform monitoring, especially during bag-valve mask ventilation, is well within the capability of EMTs
- 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)