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Is Prehospital Advanced Airway Management Harmful for Cardiac Arrest Patients?

Outcomes were better with bag-valve-mask ventilation than with advanced airway management.

Prehospital advanced airway management by paramedics has become common, but little clinical evidence supports its effectiveness. Furthermore, recent research on resuscitation of patients with out-of-hospital cardiac arrest has led to a shift in management from ABC to CAB, with good-quality chest compressions and defibrillation given priority over airway management (JW Physician's First Watch Mar 12 2008).

In a retrospective analysis of Japan's nationwide registry of out-of-hospital cardiac arrests from 2005 through 2010, researchers assessed the association between prehospital airway management methods and 30-day neurological outcomes. They used propensity score matching and stratified analysis to control for potential confounders. About 650,000 adult patients were included. Favorable neurologic outcomes occurred in 2.9% of the bag-valve-mask group, 1.0% of the intubation group, and 1.1% of the supraglottic airway group. Compared to patients managed with bag-valve-mask ventilation alone, those managed with endotracheal intubation or supraglottic airway insertion had lower odds of a favorable neurological outcome at 30 days (adjusted odds ratios, 0.45 and 0.36, respectively).

Comment: This study suggests that the chance of a good outcome after out-of-hospital cardiac arrest is at least twice as good with prehospital bag-valve-mask ventilation as with prehospital advanced airway management. In light of the lack of evidence supporting prehospital advanced airway management for patients with out-of-hospital cardiac arrest, this high-quality observational study adds to other evidence in arguing for practice change. Emergency medical services and the American Heart Association should consider revision of guidelines and deemphasize advanced airway management during prehospital cardiopulmonary resuscitation in favor of bag-valve-mask ventilation.

— Daniel J. Pallin, MD, MPH

Drs. Pallin and Walls are current or recent colleagues of some of the study authors, but they were not involved in the study.

Published in Journal Watch Emergency Medicine January 15, 2013

Citation(s):

Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.

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Reader Remarks:

Review and add to remarks on this article

• Airway Management change
  Michael Eliastam, 17 Jan 2013 2:21 PM EST
  Specialty: Emergency Medicine
  The issue of time in the field has always plagued achieving better survival rates; because of the 'sexiness' of field... [more]
• pre hospital intubation
  P marchant, Locum theatre practitioner 23 years, 25 Jan 2013 11:26 AM EST
  Specialty: Critical Care (Anesthesiology)
  ET intubation is gold standard. When your driving home after a curry and then you are subjected to an event,... [more]
• Was there a "no" bagging group?
  Harold Shim, 25 Jan 2013 11:26 AM EST
  Specialty: Emergency Medicine
  In my observation, prehospital providers bagging skills are not the best and I'm wondering if the outcomes would have been... [more]
• air way management
  Chandrasekhara ..N> Menon, Little Flower hospital Angamaly Krrala, 25 Jan 2013 11:26 AM EST
  Specialty: Hematology (Internal Medicine)
  I agree with the authors that simple methods are better in some situations. This is a study in more than... [more]
• In Hospital Airway Management
  Russell Metcalfe-Smith, 25 Jan 2013 11:26 AM EST
  Specialty: Emergency Medicine
  I cannot wait to read this paper in full - i was wondering the professional background of the authors? We... [more]
• Advanced Airway - Cardiac Arrest
  Jon D. Seiverth, 30 Jan 2013 11:25 AM EST
  Specialty: Emergency Medicine
  Simply untrue. Continuous Quality CPR is a must, even during intubation. Early access, Continuous CPR, Intubation and ITD, great teamwork... [more]

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