Category: Critical Care
Keywords: RSI, intubation, critical care, out of hospital cardiac arrest (PubMed Search)
Posted: 9/10/2024 by Mark Sutherland, MD
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Airway management in the pre-hospital setting is a matter of much controversy, and overall I will defer to my EMS colleagues, but several previous studies have failed to show a benefit to endotracheal intubation in the field as opposed to alternate approaches like a supraglottic airway. Another nod in this direction has recently come out, with Battaglini et al performing a post-hoc analysis of one of the larger studies in the history of cardiac arrest, TTM-2, looking specifically at outcomes stratified by pre-hospital airway management strategy.
Do patients who undergo endotracheal intubation in the field do better than those who get a supraglottic airway?
No, they don't. TTM-2 included 1900 patients, of whom 1702 had enough data to be included in this re-analysis. 28% got supraglottic airways, and 72% got endotracheal intubation. The groups were reasonably well matched on most characteristics, and if anything most well-known prognostic factors favored the endotracheal intubation group (very slightly). It should be noted that several outcome metrics, including modified Rankin scale, did show slight signs of benefit for the endotracheal intubation group, even sometimes in a statistically significant fashion, but fell out when a multi-regression analysis, which was the primary endpoint, was done.
Bottom Line: In pre-hospital cardiac arrest, there remains limited data to support the notion that endotracheal intubation results in better outcomes than supraglottic airway placement. You should defer to your local protocols and continue to work with your paramedics and EMS directors as evidence continues to evolve. For now, I don't think there's sufficient data to suggest that a given patient should be intubated vs undergoing supraglottic airway placement, and it is probably best to defer to the judgement, training, and protocols of your folks on scene.
Battaglini D, Schiavetti I, Ball L, Christian Jakobsen J, Lilja G, Friberg H, David Wendel-Garcia P, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Martin A, Solar M, Silvio Taccone F, Dankiewicz J, Nielsen N, Morten Grejs A, Wise MP, Hängghi M, Smid O, Patroniti N, Robba C; TTM2 trial investigators§. Association between Early Airway Intervention in the Pre-Hospital setting and Outcomes in Out of Hospital Cardiac Arrest Patients: a post-hoc analysis of the Target Temperature Management-2 (TTM2) trial. Resuscitation. 2024 Sep 5:110390. doi: 10.1016/j.resuscitation.2024.110390. Epub ahead of print. PMID: 39244144.
