Article Bites #35: The Negative association between Number of airway attempts and neuro-intact survival following OHCA

Article Summary by Casey Patrick, @cpatrick_89

Article: 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? – 1205 non-trauma OHCA patients with a 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? – Jan 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

The Results

• Age = 60’s/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%/2nd 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 # 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+ (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 SGA’s? – This isn’t a rehash of PART/AIRWAYS-2.  Overall rate of SGA use was very low.

• Mean time to airway = 5min in this study

• Yes, this is retrospective but… Very granular (especially in OHCA world)

• Incorporated monitor data PLUS audio (1200 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?

• 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 & Accompanying Figure by EMS MEd Editor Maia Dorsett, MD PhD FAEMS (@maiadorsett)