Article Bites: Significance of attempts in airway management

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

Results

• 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

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)