Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 326 Cambridge St, Ste 410, Boston, MA 02114, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 01/2013; 309(3):257-66. DOI: 10.1001/jama.2012.187612
Source: PubMed


It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation.
To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA.
Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010.
Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2.
Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. CONCLUSION AND RELEVANCE: Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

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Available from: Kohei Hasegawa, Apr 14, 2014
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    • "To remove the confounding effect of these changes, we also determined the significant factors associated with 1-Y survival in OHCAs managed without ACLS procedures (Table 3). This exclusion appeared acceptable but bias may have been introduced according to literature suggesting unfavorable influences on OHCA outcomes [26] [27] [28] [29]. "
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    ABSTRACT: Aim: The aim of the study was to determine the quality of basic life support (BLS) in out-of-hospital cardiac arrests (OHCAs) receiving bystander cardiopulmonary resuscitation (CPR) and public automated external defibrillator (AED) application. Methods: From January 2006 to December 2012, data were prospectively collected from OHCA) and impending cardiac arrests treated with and without public AED before emergency medical technician (EMT) arrival. Basic life support actions and outcomes were compared between cases with and without public AED application. Interruptions of CPR were compared between 2 groups of AED users: health care provider (HCP) and non-HCP. Results: Public AEDs were applied in 10 and 273 cases of impending cardiac arrest and non–EMT-witnessed OHCAs, respectively (4.3% of 6407 non–EMT-witnessed OHCAs). Defibrillation was delivered to 33 (13.3%) cases. Public AED application significantly improved the rate of 1-year neurologically favorable survival in bystander CPR–performed cases with shockable initial rhythm but not in those with nonshockable rhythm. Emergency calls were significantly delayed compared with other OHCAs without public AED application (median: 3 and2minutes, respectively; P b .0001). Analysis of AED records obtained from 136 (54.6%) of the 249 cases with AED application revealed significantly lower rate of compressions delivered per minute and significantly greater proportion of CPR pause in the non-HCP group. Time interval between power on and the first electrocardiographic analysis widely varied in both groups and was significantly prolonged in the non-HCP group (P =.0137). Conclusions: Improper BLS responses were common in OHCAs treated with public AEDs. Periodic training for proper BLS is necessary for both HCPs and non-HCPs.
    Full-text · Article · Oct 2014 · American Journal of Emergency Medicine
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    • "Based largely on data suggesting that interruptions in chest compressions worsen the chance of neurologically intact survival, the 2010 AHA guidelines on CPR and emergency cardiac care de-emphasized the primacy of airway maintenance and artificial respiration to shift the focus on maximizing uninterrupted circulation [3]. Indeed, the largest study of patients suffering out-of-hospital cardiac arrest (OHCA) to date reported that CPR with an advanced airway (either endotracheal intubation or supraglottic airway placement) was a significant predictor of poor neurological outcome [4]. Several factors have been proposed to explain the link between pre-hospital advanced airway management and worse outcomes, including operator experience and suboptimal execution of CPR procedures [5]. "
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    ABSTRACT: Background Placement of advanced airways has been associated with worsened neurologic outcome in survivors of out-of-hospital cardiac arrest. These findings have been attributed to factors such as inexperienced operators, prolonged intubation times and other airway related complications. As an initial step to examine outcomes of advanced airway placement during in-hospital cardiac arrest (IHCA), where immediate assistance and experienced operators are continuously available, we examined whether cardiopulmonary resuscitation efforts affect intubation difficulty. Additionally, we examined whether or not the use of videolaryngoscopy increases the odds of first attempt intubation success compared with traditional direct laryngoscopy. Methods The study setting is a large urban university-affiliated teaching hospital where experienced airway managers are available to perform emergent intubation for any indication in any out-of-the-operating room location 24 hours a day, 7 days-a-week, 365 days-a-year. Intubations occurring in all adults >18 years-of-age who required emergent tracheal intubation outside of the operating room between January 1, 2008 and December 31, 2012 were examined retrospectively. Multivariate logistic regression was used to estimate the odds of difficult intubation during IHCA compared to other emergent non-IHCA indications with adjustment for a priori defined potential confounders (body mass index, operator experience, use of videolaryngoscopy versus direct laryngoscopy, and age). Results In adjusted analyses, the odds of difficult intubation were higher when taking place during IHCA (OR=2.63; 95% CI 1.1-6.3, p=0.03) compared to other emergent indications. Use of video versus direct laryngoscopy for initial intubation attempts during IHCA, however, did not improve the odds of success (adjusted OR = 0.71; 95% CI 0.35-1.43, p = 0.33). Conclusions Difficult intubation is more likely when intubation takes place during IHCA compared to other emergent indications, even when experienced operators are available. Under these conditions, direct laryngoscopy (versus videolaryngoscopy) remains a reasonable first choice intubation technique.
    Full-text · Article · May 2014 · BMC Anesthesiology
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    • "First, the presence of a physician improves outcomes of cardiac arrest because advanced procedures, such as airway management and epinephrine use, can be done by the physician [6]. However, this possibility contradicts previous studies that found both intubation and epinephrine use to be independent predictors of poor outcome in patients with OHCA [15], [30], [31]. Second, physicians are more likely to comply with treatment guidelines and possess up-to-date knowledge than other ambulance personnel [6], [32]. "
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    ABSTRACT: The presence of a physician seems to be beneficial for pre-hospital cardiopulmonary resuscitation (CPR) of patients with out-of-hospital cardiac arrest. However, the effectiveness of a physician's presence during CPR before hospital arrival has not been established. We conducted a prospective, non-randomized, observational study using national data from out-of-hospital cardiac arrests between 2005 and 2010 in Japan. We performed a propensity analysis and examined the association between a physician's presence during an ambulance car ride and short- and long-term survival from out-of-hospital cardiac arrest. Specifically, a full non-parsimonious logistic regression model was fitted with the physician presence in the ambulance as the dependent variable; the independent variables included all study variables except for endpoint variables plus dummy variables for the 47 prefectures in Japan (i.e., 46 variables). In total, 619,928 out-of-hospital cardiac arrest cases that met the inclusion criteria were analyzed. Among propensity-matched patients, a positive association was observed between a physician's presence during an ambulance car ride and return of spontaneous circulation (ROSC) before hospital arrival, 1-month survival, and 1-month survival with minimal neurological or physical impairment (ROSC: OR = 1.84, 95% CI 1.63-2.07, p = 0.00 in adjusted for propensity and all covariates); 1-month survival: OR = 1.29, 95% CI 1.04-1.61, p = 0.02 in adjusted for propensity and all covariates); cerebral performance category (1 or 2): OR = 1.54, 95% CI 1.03-2.29, p = 0.04 in adjusted for propensity and all covariates); and overall performance category (1 or 2): OR = 1.50, 95% CI 1.01-2.24, p = 0.05 in adjusted for propensity and all covariates). A prospective observational study using national data from out-of-hospital cardiac arrests shows that a physician's presence during an ambulance car ride was independently associated with increased short- and long-term survival.
    Full-text · Article · Jan 2014 · PLoS ONE
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