Laryngeal Tubes Beat Intubation Following Heart Attack

Patients with out-of-hospital cardiac arrest (OHCA) fare better with initial laryngeal tube (LT) insertion than endotracheal intubation (ETI), according to a new study.

Researchers at the University of Texas (UT) Health Science Center (UTH; Houston, USA), the U.S. National Heart, Lung, and Blood Institute (NHLBI; Bethesda, MD, USA), and other institutions conducted a study involving 3,004 adults (median age 64 years, 60.9% men) who experienced OHCA and were treated by emergency medical service (EMS) agencies, including advanced airway management. The 27 EMS agencies were randomized to an initial airway management strategy involving LT (1,505 patients), or ETI (1,499 patients), with crossover to the alternate strategy at 3-5 month intervals. The primary outcome was 72-hour survival.

The results revealed that 72-hour survival was 18.3% in the LT group, compared to 15.4% in the ETI group. Secondary outcomes, including return of spontaneous circulation (ROSC), survival to hospital discharge, favorable neurological status at hospital discharge, and adverse events, showed a consistent superiority of LT over ETI. No major differences in airway swelling, oropharyngeal or hypopharyngeal injury, or pneumonia or pneumonitis were identified. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. The study was published on August 28, 2018, in Journal of the American Medical Association (JAMA).

“During resuscitation, opening the airway and having proper access to it is a key factor for the survival of someone who goes into cardiac arrest outside of a hospital. But one of the burning questions in prehospital emergency care has been, ‘Which is the best airway device?’” said study co-author George Sopko, MD, MPH, of the NHLBI. “This study demonstrated that just by managing the airway well in the early stage of resuscitation, we could save more than 10,000 lives every year.”

Numerous studies have highlighted the challenges facing paramedic ETI, including significant rates of tube misplacement or dislodgement, need for multiple ETI attempts, and insertion failure. ETI has also been associated with iatrogenic hyperventilation and chest compression interruptions. Alternatives to ETI include supraglottic airway (SGA) devices, which include the LT, a laryngeal mask airway, esophageal-tracheal combitube, and others. While offering ventilatory characteristics similar to ETI, SGA insertion is rapid, simple, requires less training.

Related Links:
University of Texas Health Science Center
U.S. National Heart, Lung, and Blood Institute