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ILCOR welcomes the publication of the AIRWAYS2 and PART trials

28/08/2018

Airway management has been a cornerstone of cardiac arrest treatment since the early description of advanced life support.  The International Liaison Committee on Resuscitation (ILCOR) most recently reviewed the published evidence in relation to advanced airways in 2015 and identified uncertainty about the most effective airway management strategy.[1,2]

2015 ILCOR Treatment Recommendation: We suggest using either an SGA or tracheal tube as the initial advanced airway during CPR (weak recommendation, very low-quality evidence) for cardiac arrest in any setting.

Knowledge gaps identified at that time included:

  • There are no RCTs of initial airway management during cardiac arrest.
  • The type and duration of training required for each device is unknown.
  • During the management of cardiac arrest, is a stepwise approach to airway management commonly used? It is not clear how this can be studied rigorously.

Resolving the uncertainty about the best approach to airway management was identified as one of the high priority research gaps in modern day resuscitation.[3,4]

ILCOR welcomes the publication of AIRWAYS2[5] and PART[6] in the Journal of American Medical Association (JAMA) today.  We congratulate the investigators for completing clinical trials that will inform future treatment recommendations for airway management around the world.

The AIRWAYS2 trial used a cluster randomised design to compare initial airway management with a supraglottic airway device versus tracheal intubation.  Airway management was performed by trained Paramedics working across 4 large EMS agencies in England.  The primary outcomes of the study was survival with a favourable neurological outcome (defined as a modified Rankin 0-3).  The trial enrolled 9,896 patients with non-traumatic out of hospital cardiac arrest between June 2015 and August 2017.

Initial ventilation success rates were higher in the supraglottic airway group than the tracheal intubation group (4255/4868, 87.4% versus 3473/4397, 69.4%, adjusted OR 1.92 (95% CI 1.66-2.22). The intention to treat analysis found no difference in survival with a favourable neurological outcomes between the initial airway management strategy with a supraglottic airway (311/4882, 6.4%) versus one using tracheal intubation (300/4407 ,6.8%), adjusted odds ration 0.92 (95%CI 0.77-1.09).  There were also no differences in the rate of return of spontaneous circulation or survival to hospital discharge between treatment groups.  By contrast, an a priori, sensitivity analysis, limited to patients who actually received advanced airway management, identified better survival with a favourable neurological outcome in the supraglottic airway group (3.9% versus 2.6%, adjusted odds ratio 1.57 (95% CI 1.18 - 2.07).

The Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART), a cluster randomised cross over trial, compared the effectiveness of airway management strategies with initial laryngeal tube and initial endotracheal intubation.  Airway management was performed by trained EMS personnel working across 27 US EMS agencies.  The primary outcome for the trial was 72 hour survival after the index cardiac arrest.  The trial enrolled 3004 patients between December 2015 and November 2017.

Initial airway success rates were greater in the laryngeal tube arm compared to the tracheal tube arm (90.3% versus 51.6%).  In the intention to treat population, the proportion of patients alive at 72 hours was 2.9% higher (95% CI 0.2-5.6) in the laryngeal tube group (275/1505, 18.3%) compared with the tracheal intubation group (230/1495 (15.4%).  Improvements in outcomes were also found for the rate return of spontaneous circulation on emergency department, survival to hospital discharge and survival with a favourable neurological outcome at discharge.  The trial also found a lower rate of adverse events in the laryngeal tube arm (pneumothorax and rib fractures).

These trials, along with the CAAM trial,[7] published earlier this year in JAMA will now be subject to detailed analysis by the ILCOR Advanced Life Support Task Force.  The Task Force will combine the findings from these trials with those from previously published trials to generate an updated consensus on science and treatment recommendation.

Gavin Perkins

Robert W. Neumar

 

Co-chairs, International Liaison Committee on Resuscitation

28th August 2018

References

 

1. Soar J, Callaway CW, Aibiki M, et al. Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015;95:e71-e120.


2. Callaway CW, Soar J, Aibiki M, et al. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(16 Suppl 1):S84-S145.


3. Kleinman ME, Perkins GD, Bhanji F, et al. ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement. Resuscitation. 2018;127:132-146.


4. Kleinman ME, Perkins GD, Bhanji F, et al. ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement. Circulation. 2018;137(22):e802-e819.


5. Benger JR, Kirby K, Black S, et al. 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(8):779-791.


6. Wang HE, Schmicker RH, Daya MR, 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;320(8):769-778.


7. Jabre P, Penaloza A, Pinero D, et al. 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(8):779-787.


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