Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest a randomized clinical trial

Henry E. Wang, Robert H. Schmicker, Mohamud Ramzan Daya, Shannon W. Stephens, Ahamed H. Idris, Jestin N. Carlson, M. Riccardo Colella, Heather Herren, Matthew Hansen, Neal J. Richmond, Juan Carlos J. Puyana, Tom P. Aufderheide, Randal E. Gray, Pamela C. Gray, Mike Verkest, Pamela C. Owens, Ashley M. Brienza, Kenneth J. Sternig, Susanne J. May, George R. SopkoMyron L. Weisfeldt, Graham Nichol

Research output: Contribution to journalArticle

35 Citations (Scopus)

Abstract

IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score 3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

Original languageEnglish (US)
Pages (from-to)769-778
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume320
Issue number8
DOIs
StatePublished - Aug 28 2018

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Out-of-Hospital Cardiac Arrest
Intratracheal Intubation
Randomized Controlled Trials
Airway Management
Survival
Emergency Medical Services
Pneumonia
Resuscitation
Cross-Over Studies
Clinical Trials
Wounds and Injuries

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest a randomized clinical trial. / Wang, Henry E.; Schmicker, Robert H.; Daya, Mohamud Ramzan; Stephens, Shannon W.; Idris, Ahamed H.; Carlson, Jestin N.; Riccardo Colella, M.; Herren, Heather; Hansen, Matthew; Richmond, Neal J.; Puyana, Juan Carlos J.; Aufderheide, Tom P.; Gray, Randal E.; Gray, Pamela C.; Verkest, Mike; Owens, Pamela C.; Brienza, Ashley M.; Sternig, Kenneth J.; May, Susanne J.; Sopko, George R.; Weisfeldt, Myron L.; Nichol, Graham.

In: JAMA - Journal of the American Medical Association, Vol. 320, No. 8, 28.08.2018, p. 769-778.

Research output: Contribution to journalArticle

Wang, HE, Schmicker, RH, Daya, MR, Stephens, SW, Idris, AH, Carlson, JN, Riccardo Colella, M, Herren, H, Hansen, M, Richmond, NJ, Puyana, JCJ, Aufderheide, TP, Gray, RE, Gray, PC, Verkest, M, Owens, PC, Brienza, AM, Sternig, KJ, May, SJ, Sopko, GR, Weisfeldt, ML & Nichol, G 2018, 'Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest a randomized clinical trial', JAMA - Journal of the American Medical Association, vol. 320, no. 8, pp. 769-778. https://doi.org/10.1001/jama.2018.7044
Wang, Henry E. ; Schmicker, Robert H. ; Daya, Mohamud Ramzan ; Stephens, Shannon W. ; Idris, Ahamed H. ; Carlson, Jestin N. ; Riccardo Colella, M. ; Herren, Heather ; Hansen, Matthew ; Richmond, Neal J. ; Puyana, Juan Carlos J. ; Aufderheide, Tom P. ; Gray, Randal E. ; Gray, Pamela C. ; Verkest, Mike ; Owens, Pamela C. ; Brienza, Ashley M. ; Sternig, Kenneth J. ; May, Susanne J. ; Sopko, George R. ; Weisfeldt, Myron L. ; Nichol, Graham. / Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest a randomized clinical trial. In: JAMA - Journal of the American Medical Association. 2018 ; Vol. 320, No. 8. pp. 769-778.
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abstract = "IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score 3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9{\%}] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3{\%} with LT and 51.6{\%} with ETI. Seventy-two hour survival was 18.3{\%} in the LT group vs 15.4{\%} in the ETI group (adjusted difference, 2.9{\%} [95{\%} CI, 0.2{\%}-5.6{\%}]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9{\%} vs 24.3{\%}; adjusted difference, 3.6{\%} [95{\%} CI, 0.3{\%}-6.8{\%}]; P = .03); hospital survival (10.8{\%} vs 8.1{\%}; adjusted difference, 2.7{\%} [95{\%} CI, 0.6{\%}-4.8{\%}]; P = .01); and favorable neurological status at discharge (7.1{\%} vs 5.0{\%}; adjusted difference, 2.1{\%} [95{\%} CI, 0.3{\%}-3.8{\%}]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2{\%} vs 0.3{\%}), airway swelling (1.1{\%} vs 1.0{\%}), or pneumonia or pneumonitis (26.1{\%} vs 22.3{\%}). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.",
author = "Wang, {Henry E.} and Schmicker, {Robert H.} and Daya, {Mohamud Ramzan} and Stephens, {Shannon W.} and Idris, {Ahamed H.} and Carlson, {Jestin N.} and {Riccardo Colella}, M. and Heather Herren and Matthew Hansen and Richmond, {Neal J.} and Puyana, {Juan Carlos J.} and Aufderheide, {Tom P.} and Gray, {Randal E.} and Gray, {Pamela C.} and Mike Verkest and Owens, {Pamela C.} and Brienza, {Ashley M.} and Sternig, {Kenneth J.} and May, {Susanne J.} and Sopko, {George R.} and Weisfeldt, {Myron L.} and Graham Nichol",
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TY - JOUR

T1 - Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest a randomized clinical trial

AU - Wang, Henry E.

AU - Schmicker, Robert H.

AU - Daya, Mohamud Ramzan

AU - Stephens, Shannon W.

AU - Idris, Ahamed H.

AU - Carlson, Jestin N.

AU - Riccardo Colella, M.

AU - Herren, Heather

AU - Hansen, Matthew

AU - Richmond, Neal J.

AU - Puyana, Juan Carlos J.

AU - Aufderheide, Tom P.

AU - Gray, Randal E.

AU - Gray, Pamela C.

AU - Verkest, Mike

AU - Owens, Pamela C.

AU - Brienza, Ashley M.

AU - Sternig, Kenneth J.

AU - May, Susanne J.

AU - Sopko, George R.

AU - Weisfeldt, Myron L.

AU - Nichol, Graham

PY - 2018/8/28

Y1 - 2018/8/28

N2 - IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score 3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

AB - IMPORTANCE Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score 3), and key adverse events. RESULTS Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.

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