Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Study Questions:

Compared to advanced airway management (endotracheal intubation or supraglottic airway devices), does conventional bag-valve-mask ventilation improve short-term neurologic outcomes following out-of-hospital cardiac arrest (OHCA)?


This was a prospective, nationwide, population-based study of Japanese adults who had an OHCA between 2005 and 2010, and in whom resuscitation was attempted by emergency responders. The primary endpoint was favorable neurological outcome 1 month after cardiac arrest, defined a priori as Glasgow-Pittsburgh cerebral performance category 1 or 2.


Of the 649,359 eligible patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) received advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In a propensity-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39).


Compared to conventional bag-valve-mask ventilation among Japanese adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival.


While limited to a Japanese cohort, the results from this prospective study contradict the assumption that aggressive prehospital airway management would improve outcomes for OHCA. And, although an observational study is not able to establish causality, this study does draw attention to the complexity of prehospital intubation and how it may conceivably be associated with poorer outcomes (e.g., by ‘distracting’ emergency medical services personnel from delivering high-quality cardiopulmonary resuscitation and compromising outcomes). Future studies should clarify which subsets of patients would actually benefit from prehospital advanced airway management.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Airway Management, Odds Ratio, Intubation, Out-of-Hospital Cardiac Arrest, Emergency Medical Services, Cardiopulmonary Resuscitation, Heart Arrest, Confidence Intervals, Respiration, Masks

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