Use Of Supraglottic Airway Research Articles

37 Supraglottic Airway Use vs Endotracheal Intubation Pre/Post Deployment of the i-gel Supraglottic Airway Device in a Large Ground and Air-based Emergency Medical Services Agency

37 Supraglottic Airway Use vs Endotracheal Intubation Pre/Post Deployment of the i-gel Supraglottic Airway Device in a Large Ground and Air-based Emergency Medical Services Agency

Unrecognized failed airway management using a supraglottic airway device

Background911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. MethodsRetrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider’s assessment of success were then calculated. ResultsA total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider’s assessment was 98.5%; specificity was 28.7%. ConclusionThe use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.

Comparative Assessment of Three Approaches of Teaching Nonmedically Trained Persons in the Handling of Supraglottic Airways: A Randomized Controlled Trial.

The use of supraglottic airways has been recommended in combat trauma airway management. To ensure an adequate airway management on the battlefield, suitable training concepts are sought to efficiently teach as many soldiers as possible. Our aim was to compare three approaches of teaching laypersons in the handling of supraglottic airways in a mannequin model. In this prospective randomized blinded study, 285 military service men without any medical background were divided into three groups and trained in the use of the Laryngeal Mask Airway Supreme (LMA) and the Laryngeal Tube Disposable (LT-D). The first group received a theoretical lecture, the second group was shown an instruction video, and the third group underwent a practical training. Immediately after instruction participants were asked to place the supraglottic airway and ventilate the mannequin within 60 seconds. The entire test was repeated 3 months later. Test results were evaluated with regard to success rate, insertion time, ability to judge the correct placement, and degree of difficulty. Practical training showed the highest success rate when placing supraglottic airways immediately after the instruction (lecture: 68%, video: 74%, training: 94%); (training vs. lecture and training vs. video, p < 0.001) as well as 3 months later (lecture: 63%, video: 66%, training: 78%); (training vs. lecture, p = 0.019 and training vs. video, p = 0.025). Immediately after the instruction practical training was also superior in terms of insertion time, ability to judge the correct placement, and the self-rated degree of difficulty (p < 0.001). These effects were significantly reduced 3 months after the instruction. In comparison between supraglottic airways LT-D was superior to LMA regarding all the outcome parameters mentioned above (p < 0.001). In this study, performed with personnel of the German Armed Forces, we have shown that persons without any medical and paramedical background are able to successfully place a supraglottic airway immediately following minimal instruction and after 3 months as well. Study participants achieved the best results after practical training followed by video presentation and finally lecture regardless of the airway device used. There are two possible reasons why practical training is the superior method. Firstly, the success is tied to more time spent with the learners. Secondly, practical training seems to be the best teaching method for various types of learners such as visual, auditory, reading/writing, and kinesthetic type. In addition the results of our study show that the LT-D is an ideal supraglottic airway in the hands of people inexperienced in airway management. In conclusion, our results show that practical training is the superior instruction method compared to theoretical lecture and presentation of an instruction video. Nevertheless, the presentation of an instruction video is a promising approach of teaching a maximum number of laypersons with minimal effort to correctly place supraglottic airways. To optimize the success rate of such a concept LT-Ds instead of LMAs should be used for airway management. The presented concepts hold promise for combat as well as for civilian emergency medicine.

Competence in the use of supraglottic airways by Australian surf lifesavers for cardiac arrest ventilation in a manikin.

Lifesavers in Australia are taught to use pocket mask (PM) rescue breathing and bag valve mask (BVM) ventilation, despite evidence that first responders might struggle with these devices. Novices have successfully used the Laryngeal Mask Airway (LMA) Supreme and iGel devices previously, but there has been no previous comparison of the ability to train lifesavers to use the supraglottic airways compared to standard techniques for cardiac arrest ventilation. The study is a prospective educational intervention whereby 113 lifesavers were trained to use the LMA and iGel supraglottic airways. Comparisons were made to standard devices on plastic manikins. Successful ventilation was defined as achieving visible chest rise. The median time to first effective ventilation was similar between the PM (16 s, 95% confidence interval 16-17 s), BVM (17 s, 16-17 s) and iGel devices (18 s, 16-20 s), but longer for the LMA (36 s, 33-38 s). The iGel frequently failed to achieve ventilation (10%) compared with the PM (1%, P < 0.01) and LMA (3%, P < 0.01) but was not worse than the BVM (3%, P < 0.57). Hands-off time was similar between the BVM, LMA and iGel (10 s for each device), but worse for the PM (13 s, P = 0.001). Lifesavers using the PM and BVM perform ventilation for cardiopulmonary resuscitation well. There appears to be a limited role for supraglottic airway devices because of limitations in terms of time to first effective ventilation and reliability. Clinical validation of manikin data with live resuscitation performance is required.

Extraglottic Airways in Tactical Combat Casualty Care: TCCC Guidelines Change 17-01 28 August 2017.

Extraglottic airway (EGA) devices have been used by both physicians and prehospital providers for several decades. The original TCCC Guidelines published in 1996 included a recommendation to use the laryngeal mask airway (LMA) as an option to assist in securing the airway in Tactical Evacuation (TACEVAC) phase of care. Since then, a variety of EGAs have been used in both combat casualty care and civilian trauma care. In 2012, the Committee on TCCC (CoTCCC) and the Defense Health Board (DHB) reaffirmed support for the use of supraglottic airway (SGA) devices in the TACEVAC phase of TCCC, but did not recommend a specific SGA based on the evidence available at that point in time. This paper will use the more inclusive term "extraglottic airway" instead of the term "supragottic airway" used in the DHB memo. Current evidence suggests that the i-gel® (Intersurgical Complete Respiratory Systems; http://www.intersurgical.com/info/igel) EGA performs as well or better than the other EGAs available and has other advantages in ease of training, size and weight, cost, safety, and simplicity of use. The gel-filled cuff in the i-gel both eliminates the need for cuff pressure monitoring during flight and reduces the risk of pressure-induced neuropraxia to cranial nerves in the oropharynx and hypopharynx as a complication of EGA use. The i-gel thus makes the medic's tasks simpler and frees him or her from the requirement to carry a cuff manometer as part of the medical kit. This latest change to the TCCC Guidelines as described below does the following things: (1) adds extraglottic airways (EGAs) as an option for airway management in Tactical Field Care; (2) recommends the i-gel as the preferred EGA in TCCC because its gel-filled cuff makes it simpler to use than EGAs with air-filled cuffs and also eliminates the need for monitoring of cuff pressure; (3) notes that should an EGA with an air-filled cuff be used, the pressure in the cuff must be monitored, especially during and after changes in altitude during casualty transport; (4) emphasizes COL Bob Mabry's often-made point that extraglottic airways will not be tolerated by a casualty unless he or she is deeply unconscious and notes that an NPA is a better option if there is doubt about whether or not the casualty will tolerate an EGA; (5) adds the use of suction as an adjunct to airway management when available and appropriate (i.e., when needed to remove blood and vomitus); (6) clarifies the wording regarding cervical spine stabilization to emphasize that it is not needed for casualties who have sustained only penetrating trauma (without blunt force trauma); (7) reinforces that surgical cricothyroidotomies should not be performed simply because a casualty is unconscious; (8) provides a reminder that, for casualties with facial trauma or facial burns with suspected inhalation injury, neither NPAs nor EGAs may be adequate for airway management, and a surgical cricothyroidotomy may be required; (9) adds that pulse oximetry monitoring is a useful adjunct to assess airway patency and that capnography should also be used in the TACEVAC phase of care; and (10) reinforces that a casualty's airway status may change over time and that he or she should be frequently reassessed.

Overinflation of the Cuff and Pressure on the Neck Reduce the Preventive Effect of Supraglottic Airways on Pulmonary Aspiration

(Abstracted from Br J Anaesth, 116(2):289–294, 2016) During the use of supraglottic airways, it is not possible to protect completely against gastric insufflation, gastroesophageal reflux, or subsequent pulmonary aspiration. It is crucial to identify factors that impair the sealing capacities of supraglottic airways because the risk of aspiration is always present, especially in prehospital airway management and during general anesthesia.

Impact of airway management strategies on magnetic resonance image quality

BackgroundUse of general anaesthesia or deep sedation during magnetic resonance imaging (MRI) studies leads to pharyngeal muscle relaxation, often resulting in snoring and subsequent vibrations with head micromotion. Given that MRI is very susceptible to motion, this causes artifacts and image quality degradation. The purpose of our study was to determine the effectiveness of different airway management techniques in overcoming micromotion-induced MRI artifacts. MethodsAfter obtaining institutional review board approval, we conducted a retrospective study on the image quality of central nervous system MRI studies in nine patients who had serial MRIs under general anaesthesia. All data were obtained from electronic records. We evaluated the following airway techniques: use of no airway device (NAD); oral, nasal, or supraglottic airway (SGA); or tracheal tube. To assess MRI quality, we developed a scoring system with a combined score ranging from 6 to 30. We used the linear mixed model to account for patient-dependent confounders. ResultsWe assessed 85 MRI studies from nine patients: 48 NAD, 27 SGA, four oral, four nasal, and two tracheal tube. Arithmetical mean combined scores were 21.6, 27.6, 20.3, 15.3, and 29.5, respectively. The estimated mean combined scores for the NAD and SGA cohorts were 22.0 and 27.3, respectively, showing that SGA use improved the combined score by 5.3 (P<0.0001). ConclusionsThe use of an SGA during MRI studies under general anaesthesia or deep sedation significantly improves image quality.

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation

Objectives: Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates. Methods: We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest). Results: There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41). Conclusion: Fewer patients with advanced airway management received orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways.

Because of the many advantages of supraglottic airways (SGA) compared to mask ventilation and endotracheal intubation, their areas of application are constantly expanding. The development of second-generation SGAs in particular has led to a widening of the indications for use thanks to the improved oropharyngeal leak pressure and the possibility of inserting a gastric tube. The identification of possible malpositions and any increased ventilation requirements using simple clinical tests must be given particular emphasis. The question of patient safety for expanded indications has to be evaluated. The review describes the evolution of these devices in detail with an analysis of the increased range of possible uses for prolonged application periods, minor laparoscopic procedures, obese patients, surgery in the prone position, and caesarean sections. The use of second-generation SGA for expanded indications seems useful and safe, provided the contraindications are heeded, the placement and performance tests are successfully completed and there is adequate clinical expertise.

Small is the new big: An overview of newer supraglottic airways for children.

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

Abstract 277: Supraglottic Airway Use Is Associated with Higher Chest Compression Fraction than Endotracheal Intubation During Out-of-Hospital Cardiopulmonary Arrest

Objective: Chest compression interruptions - such as those from endotracheal intubation (ETI) - are associated with poorer out-of hospital cardiac arrest (OHCA) survival. Select Emergency Medical Services (EMS) practitioners substitute ETI with supraglottic airway (SGA) insertion to minimize these interruptions, but the resulting effects upon chest compression fraction (CCF) are unknown. We sought to determine the differences in CCF between adult OHCA receiving ETI and those receiving SGA. Methods: We studied adult, non-traumatic OHCA patients enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED trial. Chest compressions were measured using compression or thoracic impedance sensors. We limited the analysis to those receiving ETI or SGA and &gt;2 minutes of chest compression data before and after airway insertion. We compared CCF between ETI and SGA before and after airway insertion, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, PRIMED trial arm, and regional ROC center. We also compared the change in CCF for each airway technique and stratified these analyses by initial rhythm. We analyzed the data using t-tests and multivariable linear regression. Results: Of 14,955 patients enrolled in the ROC PRIMED trial, we analyzed 2,767 cases, including 2051 ETI, 671 SGA, and 45 both. Unadjusted pre- and post- airway CCF was higher for SGA than ETI (pre- 0.732 vs 0.706, difference -0.026 95% CI -0.044, -0.008; post- 0.767 vs 0.724, difference -0.043 95% CI -0.060, -0.026). Adjusted post-airway CCF improved with both techniques, but the changes were not statistically significant (0.012 difference, 95% CI 0.036, -0.012, p-value 0.32). CCF differences were similar when stratified by initial rhythm. Conclusion: In this series SGA insertion was associated with a higher CCF than ETI and that difference persisted post-airway insertion. Advanced airway management strategy may minimally impact CCF.

Cranial nerve injuries with supraglottic airway devices: a systematic review of published case reports and series.

Cranial nerve injuries are unusual complications of supraglottic airway use. Branches of the trigeminal, glossopharyngeal, vagus and the hypoglossal nerve may all be injured. We performed a systematic review of published case reports and case series of cranial nerve injury from the use of supraglottic airway devices. Lingual nerve injury was the most commonly reported (22 patients), followed by recurrent laryngeal (17 patients), hypoglossal (11 patients), glossopharyngeal (three patients), inferior alveolar (two patients) and infra-orbital (one patient). Injury is generally thought to result from pressure neuropraxia. Contributing factors may include: an inappropriate size or misplacement of the device; patient position; overinflation of the device cuff; and poor technique. Injuries other than to the recurrent laryngeal nerve are usually mild and self-limiting. Understanding the diverse presentation of cranial nerve injuries helps to distinguish them from other complications and assists in their management.

Use of supraglottic airways (SGA) in patients with difficult access: a prospective, controlled, randomized manikin trial

Use of supraglottic airways (SGA) in patients with difficult access: a prospective, controlled, randomized manikin trial

Elective use of supraglottic airway devices for primary airway management in children with difficult airways

Supraglottic airways (SGAs) have an established role in airway management of difficult airways in both adults and children. However, there are limited data regarding the use of SGAs for primary airway management in children. The aim of this study is to assess the success rates and adverse events related to the use of SGAs for primary airway management during anaesthesia in children with difficult airways. A retrospective analysis of SGA use for primary airway management in the difficult airway population in a single centre over a 4-yr period was performed. Difficult airway was defined as either a history of difficult direct laryngoscopy (a documented Cormack and Lehane Grade 3 or greater and the need for an alternate device to direct laryngoscopy for successful tracheal intubation), a history of difficult mask ventilation, or both. The difficult airway condition, patient characteristic data, type and length of procedure, type and size of SGA placed, number of attempts for successful device placement, success/failure associated with the device during anaesthetic maintenance, and complications were recorded. A total of 77,272 children received general anaesthesia in a free-standing paediatric institution. Four hundred and fifty-nine patients were reported to have a difficult airway. Of those, 109 received general anaesthesia and an SGA for primary management, meeting the inclusion criteria for this study during a 4-yr period. An SGA was successfully used in 96% of these patients. In four patients, an alternative airway was needed. SGAs can be effectively utilized for airway maintenance in the paediatric difficult airway population.

Reflections on the changing scope of difficult airway management

To the Editor, The correspondence from Wanderer et al. is of great interest and highlights the usefulness of guidelines in clinical decision-making for difficult airway management. Their longitudinal data from a single institution show how difficult airway management may improve by following implementation guidelines. Nevertheless, this work also raises several questions. First, while the relationship between the introduction of the video laryngoscopes (VLS) and an increase in their utilization may seem intuitive, it is not as obvious why these authors report a reduction in the rate of fibreoptic intubations (FOI). Is it possible that VLS reduced the incidence of difficult intubations or that anesthesiologists have become more confident in rescuing an expected difficult intubation with VLS or supraglottic airways (SGAs)? Second, the use of an Eschmann tracheal tube introducer (gum elastic bougie) has increased with both direct laryngoscopy (DL) and VLS. It is understandable that these devices were used in cases of suboptimal glottic exposure, as often occurs during DL, but it is unclear why the use of bougies should also increase in cases of improved glottic visualization as with VLS. Is it because there are difficulties introducing the endotracheal tube toward the vocal cords when visual-motor coordination is still poor, and therefore proficiency has not yet been achieved? A third issue relates to the increased use of SGAs. One hypothesis is that this is a consequence of a decision to use SGAs as a first-line device. There is also a possibility that increased use of SGAs may have resulted, in part, as a consequence of failed attempts to rescue a difficult intubation or difficult ventilation. Finally, the reported incidence of difficult intubation in the two quarters that were analyzed was consistently greater with the use of SGAs than with endotracheal tubes (0.06% vs 0.03%, respectively and 0.019% vs 0.009%, respectively). It is challenging to assess whether or not this result was because placing a SGA is not as easy as it seems. Unfortunately, as the authors state in their report, assessment of the degree of difficulty in airway management depended solely on subjective experience, which may have affected the results. We anticipate that these questions will be answered in due course, as these types of retrospective analyses are extended to other institutions.

Feasibility of Supraglottic Airway Use by Combat Lifesavers on the Modern Battlefield

Airway compromise is a contributor to preventable mortality on the battlefield. Supraglottic airway devices are an accepted intervention for these casualties. Combat Medics, civilian prehospital care providers, and lay civilians have demonstrated proficiency with supraglottic airways. However, the Combat Lifesaver (CLS) course includes no instruction on their use. The purpose of this study was to assess feasibility of instructing CLS students to use a supraglottic airway (the King LT-D); compare their timed performance with that of Special Operations Combat Medics (SOCM); and assess their confidence utilizing the device. After standardized instruction, students were timed and evaluated in the placement of a King LT-D in a manikin. Student confidence was assessed by Likert-scaled surveys, and free response remarks collected before and after training. 27 of 28 CLS students successfully used a King LT-D airway device in under 60 seconds following brief instruction. Placement times were not significantly different from those of SOCM. Self-rated confidence scores improved from an initial 1.4/5 to 4.9/5 following manikin trials. Both CLS and SOCM recommended the airway for future battlefield CLS use. CLS students are capable and confident in the use of a supraglottic airway device after only brief instruction.

State of the art: Rescue intubation through supraglottic airways

The use of supraglottic airways as rescue devices in failed intubation and resuscitation has become well accepted in emergency practice. Many offer or advertise the possibility of intubation through the device, but techniques and success rates vary greatly. Intubation can be achieved blindly, with the use a bougie or introducer, or with fiberoptic guidance. In this review, I examine the evidence behind different devices with various techniques, present the data from our on-going research, suggest further research directions and propose practical guidelines for clinical use in emergencies.

Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

Results Of the eligible 649359 patients with OHCA, 367837 (57%) underwent bagvalve-mask ventilation and 281522 (43%) advanced airway management, including 41972 (6%) with endotracheal intubation and 239550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score– matched cohort (357228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. Conclusion and Relevance Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

Airway management in cardiopulmonary resuscitation

The optimal method for airway management during cardiac arrest is unknown. This review summarizes recent evidence comparing the use of basic and advanced airway interventions [insertion of supraglottic airway (SGA) devices and tracheal intubation], including the role of capnography during cardiac arrest. A large observational study [649,359 out-of-hospital cardiac arrests (OHCAs)] has shown that the risk-adjusted odds of neurologically favourable survival were higher for those treated with bag-mask ventilation compared with SGA insertion or tracheal intubation. Two recent, large observational studies suggest that tracheal intubation for OHCA may be superior to SGA use. These observational studies share an important weakness: they rely on statistical risk-adjustment to account for other factors that may influence outcome, and hidden confounders may account for the differences in outcome associated with each of the airway management strategies. Most of the evidence about airway management during cardiac arrest comes from observational studies. The best airway option is likely to be different for different rescuers, and at different time points of the resuscitation process. Properly designed, prospective, randomized trials are needed to help determine the optimal airway strategy. In our view, there is currently sufficient clinical equipoise to support such trials.

Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest

It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation. To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA. Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive 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. Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2. Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival. Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.