Advanced Airway Management During Adult Cardiac Arrest (ALS): Systematic Review

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Advanced Airway Management During Adult Cardiac Arrest

CoSTR Citation

Soar J, Nicholson TC, Parr MJ, Berg KM, Böttiger BW, Callaway CW, Deakin CD, Drennan I, Neumar RW, O’Neil BJ, Paiva EF, Reynolds JC, Sandroni C, Wang TL, Welsford M, Nolan JP, Nation K, Donnino M, Morley PT, Andersen LW. Advanced Airway Management During Adult Cardiac Arrest Consensus on Science with Treatment Recommendations [Internet ] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2019 March 18. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of advanced airway management during adult cardiac arrest (Andersen LW 2019 – PROSPERO: CRD42018115556) conducted by a systematic review team with involvement of clinical content experts from the ILCOR ALS Task Force.

Systematic review

Granfeldt A, Avis SR, Nicholson TC, Holmberg MJ, Moskowitz A, Coker A, Berg KM, Parr MJ, Donnino MW, Soar J, Nation K, Andersen LW on behalf of the Advanced Life Support Task Force of the International Liaison Committee of Resuscitation. Advanced Airway Management During Adult Cardiac Arrest: A Systematic Review. [Submitted to Resuscitation 18 March 2019]

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults any setting (in-hospital or out-of-hospital) with cardiac arrest from any etiology.

Intervention: A specific advanced airway management method (e.g. tracheal intubation or a supraglottic airway device) during cardiac arrest.

Comparators: A different advanced airway management method or no advanced airway management method (e.g. bag-mask ventilation) during cardiac arrest.

Outcomes: Survival to hospital discharge/28 days with favorable neurological outcome and survival to hospital discharge/28 days were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) that compared at least two airway strategies were eligible for inclusion. Studies with 10 or fewer patients in either group were excluded.

Timeframe: All years and all languages were included; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to October 30, 2018.

PROSPERO: CRD42018115556

Consensus on science

Laryngeal Tube versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a low tracheal intubation success rate

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.42; 95% CI 1.07-1.89; 21 more patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 3 more patients/1000 to 38 more patients/1000 survived to hospital discharge with the intervention]).

For the critical outcome of survival to hospital discharge we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.34; 95% CI 1.07-1.68; 27 more patients /1000 survived to hospital discharge with the intervention [95% CI 6 more patients/1000 to 48 more patients/1000 survived to hospital discharge with the intervention]).

Laryngeal Tube versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a high tracheal intubation success rate

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified very-low certainty evidence (downgraded for serious risk of bias, serious indirectness and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.42; 95% CI 1.07-1.89; 21 more patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 3 more patients/1000 to 38 more patients/1000 survived to hospital discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to hospital discharge we identified very-low certainty evidence (downgraded for serious risk of bias, serious indirectness and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.34; 95% CI 1.07-1.68; 27 more patients /1000 survived to hospital discharge with the intervention [95% CI 6 more patients/1000 to 48 more patients/1000 survived to hospital discharge with the intervention]).

Laryngeal Tube versus tracheal intubation for in-hospital cardiac arrest

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified very-low certainty evidence (downgraded for serious risk of bias, very serious indirectness and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.42; 95% CI 1.07-1.89; 21 more patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 3 more patients/1000 to 38 more patients/1000 survived to hospital discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to hospital discharge we identified very-low certainty evidence (downgraded for serious risk of bias, very serious indirectness and serious imprecision) from one randomized controlled trial (Wang 2018 769) enrolling 2999 adult patients with out-of-hospital cardiac arrest which showed an improved outcome with the Laryngeal Tube when compared with tracheal intubation (RR 1.34; 95% CI 1.07-1.68; 27 more patients /1000 survived to hospital discharge with the intervention [95% CI 6 more patients/1000 to 48 more patients/1000 survived to hospital discharge with the intervention]).

i-gel versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a low tracheal intubation success rate

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.92; 95% CI 0.77-1.09; 6 fewer patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 16 fewer patients/1000 to 4 more patients/1000 survived to hospital discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to hospital discharge we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.95; 95% CI 0.82-1.10; 4 fewer patients /1000 survived to hospital discharge with the intervention [95% CI 14 fewer patients/1000 to 8 more patients/1000 survived to hospital discharge with the intervention]).

i-gel versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a high tracheal intubation success rate

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified very-low certainty evidence (downgraded for serious risk of bias, serious indirectness and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.92; 95% CI 0.77-1.09; 6 fewer patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 16 fewer patients/1000 to 4 more patients/1000 survived to hospital discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to hospital discharge we identified very-low certainty evidence (downgraded for serious risk of bias, serious indirectness and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.95; 95% CI 0.82-1.10; 4 fewer patients /1000 survived to hospital discharge with the intervention [95% CI 14 fewer patients/1000 to 8 more patients/1000 survived to hospital discharge with the intervention]).

i-gel versus tracheal intubation for in-hospital cardiac arrest

For the critical outcome of survival to hospital discharge with favorable neurological outcome we identified very-low certainty evidence (downgraded for serious risk of bias, very serious indirectness and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.92; 95% CI 0.77-1.09; 6 fewer patients /1000 survived to hospital discharge with favorable neurological outcome with the intervention [95% CI 16 fewer patients/1000 to 4 more patients/1000 survived to hospital discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to hospital discharge we identified very-low certainty evidence (downgraded for serious risk of bias, very serious indirectness and serious imprecision) from one randomized controlled trial (Benger 2018 779) enrolling 9289 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with the i-gel when compared with tracheal intubation (RR 0.95; 95% CI 0.82-1.10; 4 fewer patients /1000 survived to hospital discharge with the intervention [95% CI 14 fewer patients/1000 to 8 more patients/1000 survived to hospital discharge with the intervention]).

Bag-mask ventilation versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a low tracheal intubation success rate

For the critical outcome of survival to 28 days with favorable neurological outcome we identified low certainty evidence (downgraded for serious indirectness and serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.03; 95% CI 0.68-1.55; 1 more patient /1000 survived to 28 days with favorable neurological outcome with the intervention [95% CI 13 fewer patients/1000 to 23 more patients/1000 survived to 28 days with favorable neurological outcome with the intervention]).

For the critical outcome of survival to 28 days we identified low certainty evidence (downgraded for serious indirectness and serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.02; 95% CI 0.71-1.47; 1 more patient /1000 survived to 28 days with the intervention [95% CI 18 fewer patients/1000 to 21 more patients/1000 survived to 28 days with the intervention]).

Bag-mask ventilation versus tracheal intubation for out-of-hospital cardiac arrest, in a setting with a high tracheal intubation success rate

For the critical outcome of survival to 28 days with favorable neurological outcome we identified moderate certainty evidence (downgraded for serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.03; 95% CI 0.68-1.55; 1 more patient /1000 survived to 28 days with favorable neurological outcome with the intervention [95% CI 13 fewer patients/1000 to 23 more patients/1000 survived to 28 days with favorable neurological outcome with the intervention]).

For the critical outcome of survival to 28 days we identified moderate certainty evidence (downgraded for serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.02; 95% CI 0.71-1.47; 1 more patient /1000 survived to 28 days with the intervention [95% CI 18 fewer patients/1000 to 21 more patients/1000 survived to 28 days with the intervention]).

Bag-mask ventilation versus tracheal intubation for in-hospital cardiac arrest

For the critical outcome of survival to 28 days with favorable neurological outcome we identified low certainty evidence (downgraded for serious indirectness and serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.03; 95% CI 0.68-1.55; 1 more patient /1000 survived to 28 days with favorable neurological outcome with the intervention [95% CI 13 fewer patients/1000 to 23 more patients/1000 survived to 28 days with favorable neurological outcome with the intervention]).

For the critical outcome of survival to 28 days we identified low certainty evidence (downgraded for serious indirectness and serious imprecision) from one randomized controlled trial (Jabre 2018 779) enrolling 2040 adult patients with out-of-hospital cardiac arrest which showed no difference in outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.02; 95% CI 0.71-1.47; 1 more patient /1000 survived to 28 days with the intervention [95% CI 18 fewer patients/1000 to 21 more patients/1000 survived to 28 days with the intervention]).

For the critical outcome of survival to discharge with favorable neurological outcome we identified very low certainty evidence (downgraded for very serious risk of bias) from one observational study (Andersen 2017 494) enrolling 86,862 adult patients with in-hospital cardiac arrest which showed an improved outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.28; 95% CI 1.24-1.33; 23 more patients /1000 survived to discharge with favorable neurological outcome with the intervention [95% CI 20 more patients/1000 to 27 more patients/1000 survived to discharge with favorable neurological outcome with the intervention]).

For the critical outcome of survival to discharge we identified very low certainty evidence (downgraded for very serious risk of bias) from one observational study (Andersen 2017 494) enrolling 86, 862 adult patients with in-hospital cardiac arrest which showed an improved outcome with bag-mask ventilation when compared with tracheal intubation (RR 1.20; 95% CI 1.17-1.24; 26 more patients /1000 survived to discharge with the intervention [95% CI 21 more patients/1000 to 31 more patients/1000 survived to discharge with the intervention]).

Treatment Recommendations

  • We suggest using bag-mask ventilation or an advanced airway strategy during CPR for adult cardiac arrest in any setting (weak recommendation, low to moderate-certainty evidence).
  • If an advanced airway is used, we suggest a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success rate (weak recommendation, low certainty of evidence).
  • If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate (weak recommendation, very low certainty of evidence).
  • If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with in-hospital cardiac arrest (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

  • This topic was given a high priority rank by the ILCOR ALS Task Force. This followed the publication of three new RCTs (Benger 2018 779, Jabre 2018 779, Wang 2018 769) since the previous CoSTR in 2015 (Callaway 2015 s84, Soar 2015 e71).
  • The three new RCTs have enabled the ALS Task Force to provider more specific treatment recommendations. The 2015 Treatment Recommendation was based only on evidence from observational studies with critical or serious risk of bias primarily caused by confounding and selection bias. The 2015 treatment recommendation stated: ‘We suggest using either an advanced airway or a bag-mask device for airway management during CPR (weak recommendation, very-low-quality evidence) for cardiac arrest in any setting’ (Callaway 2015 s84, Soar 2015 e71).
  • For this 2019 CoSTR, 78 observational studies were identified. Due to the risk of bias, heterogeneity between studies, and the availability of controlled trials, no meta-analyses were performed for observational studies. Eleven RCTs were identified (all addressed OHCA). Given the small sample sizes, the general high risk of bias, and the fact that some of these were published more than 15 years ago, only the three recent RCTs published in 2018 were considered in the systematic review (Benger 2018 779, Jabre 2018 779, Wang 2018 769). Due to different comparisons and heterogeneity no meta-analyses of these RCTs were undertaken.
  • There is currently no supporting evidence that an advanced airway (i.e. supraglottic airway or tracheal intubation) during CPR improves survival or survival with a favorable neurological/functional outcome after adult cardiac arrest in any setting when compared with bag-mask ventilation.
  • This ILCOR 2019 CoSTR addresses airway management during CPR in adults and not after ROSC and this is specifically stated in the treatment recommendation. Once ROSC is achieved the optimal airway technique will depend on the patient’s precise condition and skills of the rescuer. Survivors requiring mechanical ventilation and post resuscitation care will eventually require tracheal intubation.
  • In the treatment recommendation we have used the term ‘advanced airway strategy’. This is because advanced airway device placement usually starts with a variable period of bag-mask ventilation. The optimal timing and reasons for transitioning to an advanced airway vary based on the clinical context. In the three recent RCTs (Benger 2018 779, Jabre 2018 779, Wang 2018 769), patients treated with advanced airways had a period of bag-mask ventilation whilst preparing for device insertion. In some patients a supraglottic airway was inserted as the first airway intervention without bag-mask ventilation. The term ‘advanced airway strategy’ includes all of these options. In addition, depending on their particular skill set, providers may change to an advanced airway if bag-mask ventilation is difficult, and the advanced airway may be the easier technique for the provider.
  • When an advanced airway is used, we suggest that a supraglottic airway is used if the setting or specific provider has limited training and experience in tracheal intubation (i.e. there is a [anticipated] low tracheal intubation success rate). In other settings, both supraglottic airways and tracheal intubation can be considered.
  • We have not provided a precise value or range of values for low and high intubation success rate, nor an agreed definition. Studies have used different definitions of tracheal intubation success. Using the individual study definitions, we considered the Wang and Benger RCTs (Benger 2018 779, Wang 2018 769) as having a low tracheal intubation success rate (51.6% and 69.8% respectively) and the Jabre study (Jabre 2018 779) as having a high success rate (97.9%).
  • In addition, to potential harm from a low tracheal intubation success rate, the Task Force also considered the potential for harm from prolonged interruption in chest compression to achieve successful intubation.
  • There are insufficient data for us to express a preference for a particular supraglottic airway device of those currently available (the i-gel was used in the Benger RCT and the Laryngeal Tube in the Wang RCT (Benger 2018 779, Wang 2018 769). We considered that the performance of individual supraglottic airway devices varies and hence did not pool data from these two studies.
  • Effective bag-mask ventilation is not always straightforward and also varies according to provider skills. We have not specifically evaluated the optimal bag-mask technique and use of airway adjuncts (oropharyngeal or nasopharyngeal airways). For example, some training materials recommend a two-person technique for bag-mask ventilation (one rescuer using a two-handed technique to hold the face mask with a second rescuer squeezing the bag).
  • The Task Force considered that the preferred airway option will likely be provider dependent and also depend on the specific patient circumstances.
  • Our recommendation regarding airway management for the in-hospital setting is based on indirect evidence from out-of-hospital cardiac arrest trials. In addition, the Task Force considered the findings of one large observational study of in-hospital cardiac arrest (Andersen 2017 494) although this was not determining for the final treatment recommendations. We have assumed that tracheal intubation success rates are high in the in-hospital setting but acknowledge that there is limited evidence to support this assumption and that it is likely to be site-dependent.

Knowledge Gaps

  • There were no RCTs that compare bag-mask ventilation with supraglottic airway use.
  • There were no RCTs of airway management for in-hospital cardiac arrest.
  • There are no studies of using an advanced airway (supraglottic airway or tracheal intubation) as the first airway without prior bag-mask ventilation.
  • There are no RCTs comparing different types of supraglottic airway.
  • There are no studies evaluating the optimal time point during CPR to switch between different airway techniques.
  • The impact of different airway strategies on CPR quality (no-flow time), and oxygenation and ventilation during CPR is uncertain.
  • The training and clinical experience required to maintain proficiency in an airway technique is uncertain.

Evidence to Decision Tables

EtD Advanced Airway Management During Adult Cardiac Arrest

References

Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW and American Heart Association's Get With The Guidelines-Resuscitation I. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317:494-506.

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S and Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320:779-791.

Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, de Longueville D, Bouilleau G, Devaud ML, Heidet M, Lejeune C, Fauroux S, Greingor JL, Manara A, Hubert JC, Guihard B, Vermylen O, Lievens P, Auffret Y, Maisondieu C, Huet S, Claessens B, Lapostolle F, Javaud N, Reuter PG, Baker E, Vicaut E and Adnet F. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018;319:779-787.

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, 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 and Nichol G. 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;320:769-778.

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