ET vs laryngeal tube Pragmatic Airway Resuscitation Trial abstract

medicsb

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https://www.eventscribe.com/2018/SAEM/agenda.asp?h=Plenary&BCFO=PL

Results: Of 3,005 enrolled patients, 1,506 were assigned to initial LT and 1,499 to initial ETI. Patient characteristics were similar between treatment arms. Seventy-two hour survival was significantly higher for LT than ETI: 18.2% vs 15.3%, adjusted difference 2.9% (95% CI: 0.2-5.6%), p < 0.01.Secondary outcomes were significantly better for LT than ETI: ROSC 27.9% vs. 24.1%, p=0.02; hospital survival 10.8% vs 8.0%, p=0.01; favorable neurological status at discharge 7.0% vs 5.0%, p=0.02. There were no significant differences in oropharyngeal or hypopharyngeal injury, airway swelling, or pneumonia or pneumonitis.

Conclusions: In this multicenter pragmatic clinical trial in adult OHCA, initial LT was associated with significantly better clinical outcomes than initial ETI. EMS providers should consider a strategy of initial LT in adult OHCA.
 

Bullets

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this is the second place ive seen this study mentioned, though the results were not discussed, based on the OPs language i assumed it showed a better outcome with a LT than an ET. My question then and now is, can we be certain the difference in that survival was directly due to the placement of a LT and not any of the dozen or so factors that affect how a OHCA is conducted. I have numerous questions regarding the methodology and criteria chose fro this study. Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"
 

Summit

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I think Wang et al were trying to do a prospective controlled trial to answer the presumed biases confounding their previous retrospective observational study https://www.ncbi.nlm.nih.gov/pubmed/22664746

That this new controlled study had opposing results indicates prima facie indicates the assumption of observational bias were valid.

My question then and now is, can we be certain the difference in that survival was directly due to the placement of a LT and not any of the dozen or so factors that affect how a OHCA is conducted. I have numerous questions regarding the methodology and criteria chose fro this study.
Yes... it will be interesting to see the methods and controls used

Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"

With respect, you need to consider your definition of "significantly better" both in terms of statistics and human life! When we are talking about evidenced based study, significantly better means "the statistical analysis indicates that the difference in outcomes between intervention groups is likely due to the intervention rather than random chance (reject null)."

That 7% LT patients were discharged with favorable neuro outcomes can be reliably attributed (98% chance) to being in the LT group vs ETI group (5%) vs the difference being due to random chance (2% or p=0.02). That IS significant statistically, and if the difference is not otherwise explained by confounding variables or bias, it is very meaningful for practice... to the tune of 40% improvement in outcomes!!! If 40% improvement in favorable neuro outcomes isn't meaningful, what is?
 
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Carlos Danger

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Additionally, i dont know if 60 people having a better outcome qualifies as "Significantly better"

Are you serious? SIXTY MORE PEOPLE out of 3,000 had a favorable neurological outcome.....SIXTY PEOPLE.....and you arent sure that is significant?

We can certainly debate the methodology here (once we see the full text), but these stats are definitely significant, both statistically and clinically.
 

NomadicMedic

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That’s another nail in the coffin of ETI for the occasional intubator.

And I can’t say that I’m upset about it.
 

EpiEMS

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Good to see people critically reevaluating their prior findings.

Not surprised that ETI fell below LTs, particularly given the user error factor.
 

Summit

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StCEMT

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Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?
 

Summit

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Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?
It wasn't in the presentation... but all the preoxygenation data I know is for people who are NOT in cardiac arrest.

I am not aware of any evidence for improved outcomes from preoxygenation DURING CARDIAC ARREST prior to ETI. Why would it? Hands off and you aren't circulating the oxygenated blood. Plus, preoxygenation is hard when you have to pause compressions to hyperventilate with the BVM... so then you are left with putting a HFNC under the BVM... or NRB and continuous compressions... I mean you could do some trials but I'm not seeing a strong rationale why this would change for ETI vs LT (you'd do it for both groups).

I speculate hands off time is probably the the biggest contributor to the differences in outcomes, and that wouldn't change with preoxygenation. This study found that repeat attempts lead to statistically more >10sec compression pauses with ETI vs any other airway management strategy. We saw that the ETI group saw 2 or more attempts in almost half the cases. We can surmise more compression interruptions.

Meanwhile, we do know that ETI early during IHCA also has worse outcomes vs delayed (despite probably having more practiced intubators) and that video lyngoscopy doesn't decrease hands-off-chest time.

So what if you "preoxygenate" as above and then try to intubate while doing compressions? You are moving tidal volume with compressions and eliminating your preoxygenation nitrogen washout... and compressions make intubation harder so lower initial success rates. I'm not aware of any trials involving intubation during compressions. Interesting, but you are posing a completely separate intervention to be trialed.
 
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Carlos Danger

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Interesting. Has it been published?

This time the results can't be blamed on the lousy SoCal EMS systems.
 

StCEMT

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@Summit my preoxygenating question is because I respond to bystander CPR a fairly decent amount. If they have been doing compressions, blood has circulated, oxygen is reaching tissue, etc. I don't know how much. Maybe someone smarter than me can ball park it, but I don't particularly care at that point in time either. I just want to make sure I have solid ABC's immediately and I tend to blanket stuff like that simply for the sake of having a consistent routine that covers the important things.

I agree that hands off time probably has a larger role, but that makes me want to know how many people in this study stop compressions to intubate. It isn't necessary and I've found with taking time to prepare, it is easy to do. All it is are the same steps we should already be taking with maybe a little extra padding.

Anecdotal, but I have intubated 3 cardiac arrest this month. Initially successful on each using a mix of VL and DL. I don't have a timer for them, but it was pretty close to our practice runs, they were all very easy. Only one had delay and that was RIGHT before intubating due to vomiting and then suctioning, not inability to find landmarks.

Now admittedly the survival of those are 0/3. 2/3 I didnt think had a chance from the start. One was an unwitnessed arrest with likely a significant downtime. The other a multiple GSW turned arrest that I only worked because my notes made it sound like he was alive when the shooting was done, but that wasn't a certainty. I had doubts, so I worked it, but would have been completely justified in calling it on scene. I had 1/3 that maybe would have had a chance. I didn't intubate until about 10 minutes in after suctioning the vomit. What would have had more of a negative effect is the interruptions I had with autopulse failures and having to tell the FF's to get on to manual compressions. The intubation itsself though was done during compressions with fairly little time spent actively using the laryngoscope.

Now I realize my current recent calls are 0.001% of this study. Nor are all intubation attempts as easy as these. However, I have been very successful lately at intubating while CPR is being done and I credit that all to putting most of my effort into preparation before I even pick up a laryngoscope.

I can't deny the significance of the numbers this study had such as first pass success, etc. and what it says about our skills as a whole. The results arent flattering. I don't think it's wrong to question our use of intubation, I just want to know the method behind how it's done in the studies and if places that put a heavy emphasis on strong airway management ability (and the numbers to back it) have similar results.
 

Summit

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@StCEMT interesting... I looked briefly for any data on intubation during compression, didn't find any. It would be interesting to see some. Similarly, I don't see why one would have to interrupt compression to place a SGA...
 

Bullets

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Didn't see any mention in what I've seen, but is there any mention of whether or not compressions were stopped, the patients were preoxygenated, etc?
In the last slide or two the specifically say they have no data on CPR quality. Certainly an issue. I also want to know what the normal ET volume is for these agencies. Are these agencies that normally have issues or low frequency intubating? 3/4 of the reasons they give for ET failure can be remedied with practice and experience. I agree that what this study shows is that intubation is a highly perishable skill, and if the agency isnt going to make the effort to get their providers time on the blade, they should give it up for an LT

Like you ST, i work in an area that has and does a lot of intubation. My unit had 7 opportunities to intubate in April, we (my partner and i) had a first pass success rate on 6 of them, and 1 was a traumatic arrest we didnt work. Our unit averages about 7 tubes a month on 15ish night shifts. We get a ton of opportunities to intubate, and there is a difficult airway manikin set up for practice 24/7 in station. Yet with those 7 tubes, 1 survived with reasonable neuro fuction and only 2 were actually alive when we arrived. On the surface our survival numbers look like garbage
 

StCEMT

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@Summit it would be interesting to see. Again, limited experience/numbers, but comparing my success in 2017/2018 is already a night and day difference. I don't know what my '17 numbers were, but I wasn't good. I took a lot of time to reevaluate what I was doing right and wrong then made a lot of little adjustments and it's a night and day difference.

The only two good neuro outcomes I have had I attribute to two things I know for sure both had. Bystander CPR and immediate defibrillation on arrival. I never even had IV access on the last one that's how little we made it through the arrest algorithm before getting a pulse.

But even then, you're right. An SGA would not require interruptions in CPR either.

@Bullets ah, I missed that part. I have a feeling there likely are many instances of that happening. Maybe the difference between compressions + SGA vs ETT isn't significant, but that's expecting that everyone is proficient.

Out of all those you had though, what are the numbers on the other important things? Witnessed? Bystander CPR? Down time? That being said, I do agree with you. If the departments aren't supported their medics skills in this regard, do away with the intubation. My old department was straight to an igel and I absolutely loved the using it.
 

Summit

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Well now it has hit the University Press Release stage... still don't know if its peer reviewed?

10,000 lives!!!!!!
https://news.ohsu.edu/2018/05/16/em...064008&l=2772_HTML&u=1485357&mid=7304584&jb=0

phd051809s.gif
 

Bullets

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Out of all those you had though, what are the numbers on the other important things? Witnessed? Bystander CPR? Down time? That being said, I do agree with you. If the departments aren't supported their medics skills in this regard, do away with the intubation. My old department was straight to an igel and I absolutely loved the using it.
None of my OHCAs were witnessed. Of the 4, 2 we're in nursing homes with unknown down times and SNF quality CPR...The other two were at home, downtimes of an hour or so, CPR instructions over the phone

The two who were alive, both were RSI, one ended up being a massive cerebral hemorrhage that prolapsed. The one who survived was a trauma fall with a closed head injury. That patient did ok at the trauma center.

Id also like to see the breakdown by type of airway device. Did the iGel perform well? What we're the various tubes?
 

rescue1

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To stir the pot a little, here's a study that also shows poorer outcome for IN-hospital cardiac arrests who were intubated within 15 minutes of arresting, presumably by physicians with more airway experience than paramedics. However, its data from 2000-2014, and I feel like the focus on compressions over airway didn't really appear until the end of that study period.

https://jamanetwork.com/journals/jama/fullarticle/2598717
 
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