Advanced Airway Procedures for Out-of-Hospital Cardiac Arrest Associated With Poorer Neurological Outcomes






In patients with out-of-hospital cardiac arrest, cardiopulmonary resuscitation with advanced airway management, such as endotracheal intubation, was a significant predictor of poor neurological outcome compared with conventional bag-valve-mask ventilation, contradicting the assumption that an aggressive airway intervention is associated with improved outcomes, according to a study appearing in the January 16 issue of JAMA.1

“Out-of-hospital cardiac arrest (OHCA) is a major public health problem, occurring in 375,000 to 390,000 individuals in the United States each year,” according to background information in the article. The rate of survival after OHCA has increased with advances in care; however, the rate is still low, with recent estimates reporting 8 percent to 10 percent. “Although advanced airway management, such as endotracheal intubation or insertion of supraglottic [above the vocal apparatus of the larynx] airways, has long been the criterion standard for airway management of patients with OHCA, recent studies have challenged the survival benefit of advanced airway management compared with conventional bag-valve-mask ventilation in this clinical setting. However, large-scale studies evaluating the association between advanced airway management and patient-centered outcomes such as neurological status do not exist.”

Kohei Hasegawa, M.D., M.P.H., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues conducted a study to examine whether cardiopulmonary resuscitation (CPR) with any type of out-of-hospital advanced airway management by emergency medical service (EMS) personnel, compared with CPR with conventional bag-valve-mask ventilation, would be associated with favorable neurological outcome in adult OHCA. The nationwide, population-based study involved 649,654 adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010. The primary outcome for the study was favorable neurological outcome 1 month after an OHCA.

Of the eligible 649,359 patients with OHCA included in the study, 57 percent underwent bag-valve-mask ventilation and 43 percent advanced airway management, including 6 percent with endotracheal intubation and 37 percent with use of supraglottic airways. Overall, rates of return of spontaneous circulation, 1-month survival, and neurologically favorable survival were 6.5 percent, 4.7 percent, and 2.2 percent, respectively. The rates of neurologically favorable survival were 1.0 percent in the endotracheal intubation group, 1.1 percent in the supraglottic airway group, and 2.9 percent in the bag-valve-mask ventilation group, with patients in the advanced airway group having a 62 percent lower odds of a favorable neurological outcome compared with the bag-valve-mask group. The odds of neurologically favorable survival were significantly lower both for endotracheal intubation and for supraglottic airways.

“Our observations contradict the assumption that aggressive airway intervention is associated with improved outcomes and provide an opportunity to reconsider the approach to prehospital airway management in this population,” the authors write.

“Should clinicians avoid advanced airway management during CPR based on the best available observational evidence? Although one option would be to remove advanced airway management from the skill set of all out-of-hospital rescuers, that approach would disregard situations in which advanced airway management would be expected to be efficacious, especially for long-distance transfers and respiratory failure not yet with cardiac arrest. Future research will need to identify whether there are subsets of patients for whom prehospital advanced airway management is beneficial.”

In an accompanying editorial2,  Henry E. Wang, M.D., M.S., of the University of Alabama School of Medicine, Birmingham, and Donald M. Yealy, M.D., of the University of Pittsburgh, write that the “study by Hasegawa et al sends a clear message.”

“Emergency medical services professionals across the world must engage in the scientific process. A large, well-designed research effort is needed to define the benefit from endotracheal intubation, supraglottic airway insertion, or more simple actions during resuscitation after cardiac arrest. Absent this investment, the emergency medical services community risks turning a blind eye and embracing ineffective or harmful airway interventions. Patients with cardiac arrest and the out-of-hospital rescuers who care for them deserve to know what is best.”


1. JAMA. 2013;309(3):257-266; 

2. (JAMA. 2013;309(3):285-286;