Dallas 2015

TFQO: Jerry Nolan #310EVREV 1: Jerry Nolan COI #301EVREV 2: Charles Deakin COI #221Taskforce: ALS

ALS 714 : Advanced airway placement (SGA vs TT)

Dallas 2015COI Disclosure (SPECIFIC to this systematic review)

Jerry Nolan COI #310Commercial/industry

• Editor-in-Chief Resuscitation

Potential intellectual conflicts• Co-applicant AIRWAYS-2 (igel versus intubation) NIHR Funded

Charles Deakin COI #221Commercial/industry

• Editorial Board, Resuscitation• Director, Prometheus Medical

Potential intellectual conflicts• TMG, AIRWAYS-2 (igel versus intubation) NIHR Funded

Dallas 20152010 TR

Healthcare professionals trained to use supraglottic airway devices may consider their use for airway management during cardiac arrest and as a backup or rescue airway in a difficult or failed tracheal intubation.

Dallas 2015C2015 PICO

Population:patients in cardiac arrest in any setting

Intervention:Insertion of supraglottic airway as first advanced airway

Comparison:Tracheal intubation as first advanced airway

Outcomes:Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year (9-Critical)Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year (8-Critical) Change ROSC, CPR parameters, aspiration pneumonia

Dallas 2015Inclusion/Exclusion& Articles Found

The search yielded a total of 369 studies. Of these, 2 RCTs and 15 observational studies were included for bias assessment.4 studies excluded after bias assessment because they reported only blood gas data

Dallas 2015 Risk of Bias in RCTs

Dallas 2015

Risk of Bias in non-RCTs

Dallas 2015Proposed Consensus on Science statements

EGTA (I) versus tracheal intubation (C) For the critical outcome of survival to hospital discharge we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and imprecision) from one RCT enrolling 175 OHCAs show no difference between EGTA and tracheal intubation (OR 1.19 95% CI 0.5 - 3.0) [Goldenberg 1986 90]Combitube (I) versus tracheal intubation (C)For the critical outcome of survival to hospital discharge we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and imprecision) from one RCT enrolling 173 OHCAs that showed no difference between Combitube and tracheal intubation (OR 2.38 95% CI 0.5 – 12.1) [Rabitsch 2003 27] and very low quality evidence from one observational study of 5822 OHCAs that showed no difference between tracheal intubation by paramedics and Combitube insertion by emergency medical technicians (EMTs) (adjusted OR 1.02; 95% CI 0.79 -1.30) [Cady 2009 495].For the important outcome of ROSC we have identified very low quality evidence from one observational study of 5822 OHCAs that showed no difference between tracheal intubation by paramedics and Combitube insertion by emergency medical technicians (EMTs) (adjusted OR 0.93; 95% CI 0.82 -1.05). [Cady 2009 495].

Dallas 2015Proposed Consensus on Science statements

LMA (I) versus tracheal intubation (C)For the critical outcome of survival to hospital discharge we have identified very low quality evidence from one observational study of 641 OHCAs that showed lower rates of survival to hospital discharge with insertion of an LMA compared with tracheal tube (OR 0.69; 95% CI 0.4 – 1.3) [Shin 2012 313]

Supraglottic airways (SGAs: Combitube, LMA, laryngeal tube) versus tracheal intubationFor the critical outcome of favourable neurological survival we have identified low quality evidence from one observational study of 5377 OHCAs showing no difference between tracheal intubation and insertion of a SGA (adjusted OR 0.71; 95% CI 0.39 – 1.30) [Kajino 2011 R236], from one observational study of 281,522 OHCAs showing higher rates of favourable neurological outcome between insertion of a SGA and tracheal intubation (OR 1.11; 95% CI 1.0 – 1.2) [Hasegawa 2013 257] and from two studies showing higher rates of favourable neurological outcome between tracheal intubation and insertion of a SGA (8701 OHCAs adjusted OR 1.44; 95% CI 1.10 – 1.88 [McMullan 2014 617]) and (10,455 OHCAs adjusted OR 1.40; 95% CI 1.04 – 1.89 [Wang 2012 1061]).

Dallas 2015Proposed Consensus on Science statements

Supraglottic airways (SGAs: Combitube and LMA) versus tracheal intubationFor the important outcome of ROSC we have identified very low quality evidence from one observational study of 713 OHCAs that showed no difference between tracheal intubation and Combitube or LMA insertion by EMTs or emergency life-saving technicians (ELTs) (OR 0.65; 95% CI 0.4 – 1.2). [Yanagawa 2010 340].

Dallas 2015Proposed Consensus on Science statementsSupraglottic airways (SGAs: Esophageal obturator airway and LMA) versus tracheal

intubation• For the critical outcome of neurologically favourable one-month survival we have identified

very low quality evidence from one observational study of 138,248 OHCAs that showed higher rates of neurologically favourable one-month survival with tracheal intubation compared with insertion of an esophageal obturator airway or LMA (OR 0.89; 95% CI 0.8 – 1.0). [Tanabe 2013 389]

• For the critical outcome of one-year survival we have identified very low quality evidence from one observational study of 923 OHCAs that showed no difference in one-year survival with tracheal intubation compared with insertion of an esophageal obturator airway or LMA (OR 0.89; 95% CI 0.3 – 2.6). [Takei 2010 715].

• For the critical outcome of one-month survival we have identified very low quality evidence from one observation study that showed no difference in one-month survival between tracheal intubation and insertion of an esophageal obturator airway of an LMA (OR 0.75; 95% CI 0.3 – 1.9) [Takei 2010 715] and very low quality evidence from another observation study that showed higher one-month survival with tracheal intubation compared with insertion of an esophageal obturator airway of an LMA (OR 1.03; 95% CI 0.9 – 1.1) [Tanabe 2013 389]

• For the important outcome of ROSC we have identified very low quality evidence from one observational study of 923 OHCAs that showed a higher rate of ROSC with tracheal intubation compared with insertion of an esophageal obturator airway or LMA (OR 0.71; 95% CI 0.4 – 1.2). [Takei 2010 715].

Dallas 2015Draft Treatment Recommendations

We suggest using either a supraglottic airway or tracheal tube as the initial advanced airway management during CPR (weak recommendation, very low quality evidence) for out of hospital cardiac arrest.We suggest using either a supraglottic airway or tracheal tube as the initial advanced airway management during CPR (weak recommendation, very low quality evidence) for in hospital cardiac arrest.

Dallas 2015

Values and preferences

The type of airway used may depend on the skills and training of the healthcare provider. Tracheal intubation requires considerably more training and practice.Tracheal intubation may result in unrecognised oesophageal intubation and increased hands off time in comparison with insertion of a supraglottic airway.Both a supraglottic airway and tracheal tube are frequently used in the same patients as part of a stepwise approach to airway management but this has not been formally assessed.

Dallas 2015Next Steps

This slide will be completed during Task Force Discussion (not EvRev) and should include:

Consideration of interim statementPerson responsibleDue date