PART
Trial question
What is the effect of a strategy of initial laryngeal tube insertion among adults with out-of-hospital cardiac arrest?
Study design
Multi-center
Open label
RCT
Population
Characteristics of study participants
39.0% female
61.0% male
N = 3004
3004 patients (1175 female, 1829 male).
Inclusion criteria: adult patients with out-of-hospital cardiac arrest and an anticipated need for advanced airway management.
Key exclusion criteria: advanced airway device inserted prior to participation, pre-existing tracheostomy, asphyxial cardiac arrest, LV assist device, or total artificial heart.
Interventions
N=1505 laryngeal tube (insertion of a supraglottic airway as an initial airway management strategy).
N=1499 endotracheal intubation (insertion of a plastic breathing tube through the mouth and into the trachea as initial airway management strategy).
Primary outcome
Survival to 72 hour
18.3%
15.4%
18.3 %
13.7 %
9.2 %
4.6 %
0.0 %
Laryngeal
tube
Endotracheal
intubation
Significant
increase ▲
NNT = 34
Significant increase in survival to 72 hour (18.3% vs. 15.4%; AD 2.9%, 95% CI 0.2 to 5.6).
Secondary outcomes
Significant increase in return of spontaneous circulation on emergency department arrival (27.9% vs. 24.3%; AD 3.6%, 95% CI 0.3 to 6.8).
Significant increase in survival to hospital discharge (10.8% vs. 8.1%; AD 2.7%, 95% CI 0.6 to 4.8).
Significant increase in favorable neurologic status at discharge, mRS score ≤ 3 (7.1% vs. 5%; AD 2.1%, 95% CI 0.3 to 3.8).
Safety outcomes
No significant differences in oropharyngeal or hypopharyngeal injury, airway swelling, pneumonia, aspiration pneumonitis.
Significant differences in airway insertion attempts (4.5% vs. 18.9%), unsuccessful initial airway insertion (11.8% vs. 44.1%), pneumothoraces (3.5% vs. 7.0%), rib fractures (3.3% vs. 7.0%).
Conclusion
In adult patients with out-of-hospital cardiac arrest and an anticipated need for advanced airway management, laryngeal tube was superior to endotracheal intubation with respect to survival to 72 hour.
Reference
Henry E Wang, Robert H Schmicker, Mohamud R Daya et al. 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. 2018 Aug 28;320(8):769-778.
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