Abstract
Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial. To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA. The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020. Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period. The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed. A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2. In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion. ClinicalTrials.gov Identifier: NCT02967952.
Highlights
Out-of-hospital cardiac arrest (OHCA) causes the death of hundreds of thousands of people yearly worldwide,[1] including more than 10 000 people per year in Taiwan.[2]
The odds ratio of ETA vs supraglottic airway (SGA) was 1.04 for prehospital return of spontaneous circulation (ROSC), 1.00 for survival to hospital discharge, and 0.99 for cerebral performance category scores less than or equal to 2
In this randomized clinical trial, among patients with OHCA, initial airway management with endotracheal intubation (ETI) did not result in a favorable outcome of sustained ROSC compared with SGA device insertion
Summary
Out-of-hospital cardiac arrest (OHCA) causes the death of hundreds of thousands of people yearly worldwide,[1] including more than 10 000 people per year in Taiwan.[2]. Less than 5% of patients can survive until hospital discharge.[3]. Prehospital management includes basic and advanced life support, which are vital to patient outcomes.[4]. Tools in airway management are controversial in randomized clinical trials.[5,6]. Wang et al[6] found that initial supraglottic airway (SGA) insertion was associated with greater 72-hour survival compared with initial endotracheal tube insertion; the firstattempt success rate was relatively low at 51% during the study period, compared with 69% in the study conducted by Benger et al.[5]. Benger et al stated that, in terms of 30-day favorable functional outcome, SGA devices are similar to endotracheal intubation (ETI).[5]
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