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
Figure/courtesy Maia Dorsett, MD, PhD, FAEMS
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:

Read more:

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

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)

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