Intubation during resuscitation – studies decreasing it’s value

I attached more evidence of the harm caused by intubation of patients in cardiac arrest in-hospital or out of hospital. The JAMA article attached demonstrated the harm caused by the rush to intubate in-hospital patients during cardiac arrest. Early intubation resulted in poorer outcomes:

 

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival  Abstract and snippets below:

RESULTS

The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

CONCLUSIONS AND RELEVANCE

Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

Since 2010, guidelines have deemphasized the importance of tracheal intubation during cardiac arrest in adults, and the most optimal approach to airway management during cardiac arrest remains unknown. The 2015 guidelines of both the American Heart Association and the European Resuscitation Council state that either a bag-valve-mask device or an advanced airwaymay be used for ventilation and oxygenation during cardiac arrest, and the guidelines make no distinction between the out-of-hospital and in-hospital setting. 

2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

A large Japanese observational study of out-of-hospital cardiac arrest showed that advanced airway management was associated with a decreased chance of good outcome  Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Data source: Get With The Guidelines Registry

In this large,multicenter, retrospective, observational,matched cohort study, tracheal intubation at anyminute within the first 15 minutes during in-hospital cardiac arrest, compared with no intubation during that minute, was associated with a 3% absolute reduction and 16% relative reduction in survival to hospital discharge. Intubation was also associated with a 2% absolute reduction and 3% relative reduction in ROSC and a 3% absolute reduction and 22% relative reduction in good functional outcome at hospital discharge. An observational study (n = 470) from 1990 of patients with in-hospital cardiac arrest found that tracheal intubation during the cardiac arrest was associated with increased mortality,20 similar to an observational study from 2001 (n = 445). A  large observational study (n = 649 359) from Japan found that tracheal intubation during out-of-hospital cardiac arrest was associated with decreased odds of neurologically favorable survival. In this study, there were important differences in several prespecified subgroup analyses. Tracheal intubation was associated much more strongly with decreased survival among patients with an initial shockable rhythm (32% relative decrease) compared with those with an initial nonshockable rhythm (9% relative decrease). Similar subgroup differences have been reported in the out-of-hospital setting. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest  

A prior meta analysis demonstrated worse survival with advanced airway interventions:

Airways in Out-of-hospital Cardiac Arrest Systematic Review and Meta-analysis   Results. This meta-analysis included 388,878 patients. The short-term survival for AAI compared to BAI were overall OR 0.84(95% CI 0.62 to 1.13), for endotracheal intubation (ETI) OR 0.79 (95% CI 0.54 to 1.16), and for supraglottic airways (SGA) OR 0.59 (95% CI 0.39 to 0.89). Long-term survival for AAI were overall OR 0.49 (95% CI 0.37 to 0.65), for ETI OR 0.48 (95% CI 0.36 to 0.64), and for SGA OR 0.35 (95% CI 0.28 to 0.44). Sensitivity analyses shows that limiting analyses to adults, non-trauma victims, and instances where AAI was both attempted and successful did not alter results meaningfully. A third of all studies did not adjust for any other confounding factors that could impact on survival. Conclusions. This meta-analysis shows decreased survival for AAIs used out-of-hospital in cardiac arrest, but are likely biased due to confounding, especially confounding by indication. A properly conducted prospective study or a controlled trial is urgently needed and are possible to do.

Further Information from the  study verbatim:

The current study also identified an important subgroup difference according to preexisting respiratory insufficiency: intubation was not significantly associated with outcomes in those with preexisting respiratory insufficiency. A proportion of patients with preexisting respiratory insufficiency might have had cardiac arrest as a consequence of respiratory failure, and early advanced airway management could be beneficial for these patients. Although the effect estimate varied according to subgroup, intubation was not associated with improved survival in any of the subgroups.

A few relatively small randomized trials have been conducted in the out-of-hospital setting comparing various airway devices vs usual care or tracheal intubation, finding no differences in clinical outcomes between groups.

Trial of Continuous or Interrupted Chest Compressions during CPR  In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions.

Esophageal Gastric Tube Airway vs Endotracheal Tube in Prehospital Cardiopulmonary Arrest   We evaluated the efficacy ofthe esophageal airway (EA) by prospectively randomizing 175 prehospital cardiopulmonary arrest patients to receive either an esophageal gastric tube airway (ECTA) or an endotracheal tube (ET~ If attempts with the initial airway failed, the alternate airway was attempted. The cost of training paramedics in EA use was considerably less than the ET($80 vs ‘l,OOO~ Survival to the emergency room, to hospitalization and to discharge in ET and EGTA groups were 64.4 percent, 1S.6 percent, ILl percent, and 54.1 percent, 27.1 percent, 12.9 percent, respectively-differences not statistically significant. The incidence ofneurologic residual (ET 50 percent, EGTA 36.4 percent) and congestive heartfailure (ET40 percent, ECTA 45.5 percent) in surviving ET and EGTA patients did not differ (NS~ An additional 125consecutive patients with only the opporbmity to receive an EA were also evaluated and did not differ in mortality, neurologic residual, or congestive heartfailure from ETpatients. We conclude that theEA is a s~tisfactory a1temative to the ETfor short-term prehospital use in cardiopulmonary arrest patients.

 

 

 

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