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Accepted Manuscript

Advanced airway management in out of hospital cardiac arrest: Asystematic review and meta-analysis

Leigh White, Thomas Melhuish, Rhys Holyoak, Thomas Ryan,Hannah Kempton, Ruan Vlok

PII: S0735-6757(18)30800-3DOI: doi:10.1016/j.ajem.2018.09.045Reference: YAJEM 57832

To appear in: American Journal of Emergency Medicine

Received date: 29 July 2018Revised date: 16 September 2018Accepted date: 25 September 2018

Please cite this article as: Leigh White, Thomas Melhuish, Rhys Holyoak, Thomas Ryan,Hannah Kempton, Ruan Vlok , Advanced airway management in out of hospital cardiacarrest: A systematic review and meta-analysis. Yajem (2018), doi:10.1016/j.ajem.2018.09.045

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https://doi.org/10.1016/j.ajem.2018.09.045



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Title: Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis.

Leigh White1,2#, Thomas Melhuish3,4, Rhys Holyoak5, Thomas Ryan6,7, Hannah Kempton4,8 & Ruan Vlok4,7,9.

Affiliations:

1. School of Medicine, University of Queensland, Brisbane, QLD, Australia

2. Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine

Coast, QLD, Australia

3. Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW Australia

4. Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia

5. Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia

6. Department of Orthopaedics, John Hunter Hospital, Newcastle, NSW Australia

7. Sydney Clinical School, University of Notre Dame, Sydney, NSW Australia

8. Department of Medicine, St Vincent’s Hospital, Sydney, NSW, Australia

9. Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia

#Corresponding Author: Dr Leigh White

E: [email protected]

Ph: +61437216057

A: 12 Macon St, Birtinya, QLD, Australia, 4575

Word Count (excluding title page, abstract, figures, tables and reference list): 2,708

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Title: Advanced airway management in out of hospital cardiac arrest: A Systematic Review and Meta-Analysis

Abstract:

Objectives: To assess the difference in survival and neurological outcomes between endotracheal tube (ETT)

intubation and supraglottic airway(SGA) devices used during out-of-hospital cardiac arrest(OHCA).

Methods: A systematic search of five databases was performed by two independent reviewers until September

2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation

versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively

included/excluded patients, (3)in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was

used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3)

survival to hospital discharge, (4) discharge with a neurologically intact state.

Results: Twenty-nine studies (n=539,146) showed that overall, ETT use resulted in a heterogeneous, but

significant increase in ROSC (OR=1.44; 95% CI=1.27 to 1.63; I2=91%; p<0.00001) and survival to admission

(OR=1.36; 95%CI=1.12 to 1.66; I2=91%; p=0.002). There was no significant difference in survival to discharge

or neurological outcome(p>0.0125). On sensitivity analysis of RCTs, there was no significant difference in

ROSC , survival to admission, survival to discharge or neurological outcome (p>0.0125). On analysis of

automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR=1.55;

95%CI=1.20 to 2.00; I2=0%; p=0.0009) and survival to admission (OR=2.16; 95%CI=1.54 to 3.02; I2=0%;

p<0.00001).

Conclusions: The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs,

with no significant difference in survival or neurological outcome. In the presence of automated chest

compressions, ETT intubation may result in survival benefits.

Abstract Word Count: 245

Key Words: cardiac arrest, intubation, advanced airway management, laryngeal mask, laryngeal tube

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Introduction:

Out of Hospital Cardiac Arrest (OHCA) is the third leading cause of death in the United States and represents a

significant public health concern [1]. OHCA is a heterogeneous and time critical condition with a variety of

aetiologies, and little is known about the benefits of various interventions [2]. Previous guidelines have reduced

the emphasis on endotracheal intubation as an airway management strategy, although optimal airway

management remain uncertain [2].

Advanced airway management strategies for OHCA include endotracheal tube (ETT) intubation or use of

supraglottic airway (SGA) devices. ETT intubation is traditionally considered a definitive airway, although

greater skill is required for its placement and the process of securing the airway may be associated with

unrecognized misplacement of the tube, increased number of attempts and interruptions to chest compressions

[3,4]. Since previous meta-analyses [5], a number of studies have renewed interest in establishing optimal

airway management strategies for OHCA [6-8].

The aim of this study is to perform the most thorough and up to date systematic review and meta-analysis to

assess the difference in survival and neurological outcomes between ETT intubation and SGA devices for

advanced airway management in OHCA.

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Methods:

This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO;

CRD42018100126). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

guideline was followed.

Search Strategy:

A systematic search was performed by two independent reviewers (LW & RV). The search included SCOPUS,

PubMed, Medline, Cochrane Central Register of Controlled Trials and Web of Science. This search was

conducted from the inception of the databases until September, 2018. The search was performed using Medical

Subject Headings (MeSH) terms, which included: “Airway management” plus “cardiac arrest”; “Emergency

Medical Service” plus “out-of-hospital cardiac arrest” plus “airway management”. The term “Airway

Management” consists of MeSH terms “intubation”, “laryngeal mask” and “positive pressure respiration”.

“Emergency Medical Service” consists of MeSH terms “ambulance” and “prehospital emergency care”. For

completeness, a manual reference check of a recent review (5) and other accepted papers was performed to

identify any additional studies.

Eligibility Criteria:

For a study to be included in this meta-analysis the authors were required to report on (1) cardiac arrest or

cardiopulmonary resuscitation (2) endotracheal intubation versus supraglottic airway device intubation.

Supraglottic airway devices included laryngeal masks and laryngeal tubes. Clinical outcomes of interest were

required to be presented (no systematic review or meta-analysis). Only out of hospital cardiac arrest studies

were eligible for inclusion. Two reviewers (LW & RV) assessed agreed upon each study for inclusion in this

systematic review. All study designs were eligible for inclusion.

Exclusion Criteria:

Manikin and simulation studies were excluded. Studies that selectively included or excluded patients were

ineligible, for example witnessed cardiac arrest patients. In hospital cardiac arrests were not eligible for

inclusion.

Outcomes:

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The primary outcomes of interest included (1) return of spontaneous circulation (ROSC) (2) survival to hospital

admission (3) survival to hospital discharge (4) survival to discharge with a cognitively intact state. An intact

neurological state was defined as a cerebral performance category one or two or modified Rankin scale <3. All

included studies were screened for additional common outcomes for post hoc analysis.

Data collection and extraction:

Two reviewers (LW and RV) independently extracted data from each article that met the inclusion criteria. The

data extracted from each study included the study design, sample size, airway device, cause of cardiac arrest,

registry utilized and outcome measures. The data collected by each reviewer was then compared for

homogeneity.

Risk of Bias:

Two independent reviewers assessed each study for risk of bias. Two separate tools were used. Randomised

controlled trials (RCTs) were assessed for risk of bias and methodological quality using the Cochrane

Collaboration’s tool for assessing the risk of bias [9]. Non-randomised were assessed using the ROBINS-I

tool.[10]

Statistical Analyses:

The combined data was analysed using RevMan 5.3 software (The Nordic Cochrane Centre, Copenhagen,

Denmark). Dichotomous outcomes were analysed using an Odds Ratio (OR) with 95% confidence interval (CI).

The Mantel-Haenszel (M-H) random effects model was used. The absolute difference between the two groups

was measured utilizing the risk difference with 95%CIs. Heterogeneity was assess using the I2 statistic, with an

I2>50% indicating significant heterogeneity. Given we intended to assess four outcome measures, we used the

Bonferroni method to minimise the risk of type one errors. Therefore a p value of <0.0125 provided evidence of

significant OR.

Subgroup and Sensitivity Analyses:

Pre-specified sensitivity analyses were performed based on care provider, manual chest compressions, automatic

chest compressions, laryngeal mask use, laryngeal tube use, cause of arrest, location of arrest and study quality.

In the case of studies utilizing duplicate databases, two authors (LW & RV) independently decided which

duplicates to exclude on sensitivity analysis. Any disagreements were settled by a third reviewer (TM).

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Assessment of Quality of Evidence:

The quality of evidence and confidence in estimates of effect were assessed using the GRADE (Grades of

Recommendation, Assessment, Development and Evaluation) approach [11]. This approach was performed by

considering the within study risk of bias, heterogeneity between studies, effect estimate precision and the risk of

publication bias. Publication bias and small-study effects were assessed via funnel plots of standard errors

versus effect estimates. This study was written in accordance with the Meta-analysis Of Observational Studies

in Epidemiology (MOOSE) checklist [12].

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Results:

Literature Search Results:

The systematic literature search yielded 29 studies for inclusion in this meta-analysis. The initial electronic

search identified 1,494 studies and a further 17 were identified on manual reference and citation searches.

Following the removal of duplicate records and title screening, 109 abstracts were reviewed. Sixty-three full text

studies were reviewed to identify the 26 included studies. There were no disagreements between the two

authors performing the search review. In total data from 539,146 patients were included. Details on the

individual excluded studies are listed in Table S1 [13-48].

Insert Figure 1 Here.

Insert Table 1 Here.

Risk of Bias:

Each study was then screened for risk of bias and methodological quality using the Cochrane Collaboration’s

tool for assessing the risk of bias for RCTs and the ROBINS-I tool for non-randomised studies (Table S2).

Included in this meta-analysis were five low risk RCTS, eight moderate risk non-randomised studies and sixteen

serious risk non-randomised studies.

Database Duplication and Outcome Measures:

Of the twenty-six studies included, eight overlapping registry trials were found. Various studies performed in

Japan were included in this meta-analysis [6,57,59,64,65,68,69,71]. However, due to the time span of the

Fukuda et.al. study (2005 – 2014 inclusive), which included Japan-wide data, some studies [59,64,65,69,71]

were omitted to avoid the duplication of information. Despite taking place within the same time span as the

Fukuda study, studies by Hasegawa et al. and Takei et al. were included within the subgroup analysis. These

studies provided information regarding patient ROSC prior to hospital arrival, and also additional data from the

2004 to 2005 period, respectively. Within each subgroup analysis the omitted studies from overlapping

registries were eligible for inclusion if in lieu of results from Fukuda et.al. or Hasegawa et al. and Takei et al.

All studies were individually screened and no additional outcomes were identified for post-hoc analysis.

ROSC:

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Twenty-three studies (n=397,158) investigated the effect of advanced airway management on ROSC showing a

significant increase with ETT (OR= 1.44; 95%CI= 1.27 to 1.63; I2= 91%; p<0.00001; Table 2) [7,49-73,75].

The funnel plot of the overall result was skewed to the right (Figure S1). Based on the GRADE framework this

was judged to be very low quality evidence. There was no change in significance or heterogeneity with

removal of duplicate databases. On subgroup analysis for resuscitation variables EMT provider and manual

chest compressions remained significantly in favour of ETT (p<0.0125) with significant heterogeneity. The

only outcome to have a significant increase in ROSC without heterogeneity was cardiac arrest using automated

chest compressions (OR= 1.55; 95%CI=1.20 to 2.00; I2=0%; p=0.0009). On analysis of moderate and serious

risk studies, the significant benefit of ETT with significant heterogeneity remained. The significant effect was

lost without heterogeneity on analysis of low risk RCTs (OR=0.92; 95%CI= 0.80 to 1.05; I2= 23%; p=0.22).

Insert Table 2 Here

Survival to Admission:

Fourteen studies (n=51,756) investigated survival to admission, with a significant increase with ETT (OR=1.36;

95%CI= 1.12 to 1.66; I2= 91%; p=0.002; Table 3) [7,49-51,53,54,56,59,62,65,66, 73, 74]. The funnel plot of

the overall result was skewed to the right (Figure S2). Based on the GRADE framework this was judged to be

very low quality evidence. There was no change in significance or heterogeneity with removal of duplicate

databases. On sensitivity analysis for resuscitation variables LMA and laryngeal tube, there was no significant

difference with significant heterogeneity (Table 3). Without significant heterogeneity, there was a significant

increase in survival to admission with ETT during automated chest compressions (OR=2.16; 95%CI= 1.54 to

3.02; I2=0%; p<0.00001). On analysis of the low risk RCTs there was no significant difference between ETT

and SGA (OR= 0.97; 95%CI= 0.68 to 1.09; I2=0%; p=0.59).

Insert Table 3 Here

Survival to Discharge:

Twenty-two studies (n=440,564) investigated survival to discharge with no significant difference with ETT

compared to SGA (OR=1.28; 95%CI= 1.02 to 1.60; I2=96%; p=0.03; Table 4) [6,7,50-57,59,61,62,65,67-69,71,

73-75]. The funnel plot of the overall result was skewed to the right (Figure S3). Based on the GRADE

framework this was judged to be very low quality evidence. There was no change in significance or

heterogeneity with removal of duplicate databases. The subgroup analysis there was no change in non-

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significance with laryngeal tubes, whereas the LMA subgroup had reached significance over ETT with

heterogeneity (OR= 1.80; 95%CI= 1.14 to 2.83; I2= 85%; p=0.01) (Table 4). Subgroup analysis for automated

chest compressions was unable to be performed. There was no significant difference in survival to discharge in

the low risk RCTs (OR=0.90; 95%CI= 0.68 to 1.20; I2=70%; p=0.49; Table 4).

Insert Table 4 Here

Survival to discharge with a neurologically intact state:

Fourteen studies (n=438,261) showed no significant difference (p>0.0125) in discharge with a neurologically

intact state (p=0.16; Table 5) [6,7,52,57,59,60,62,65,67,69-71,73,75]. The funnel plot of the overall result was

skewed to the right (Figure S4). Based on the GRADE framework this was judged to be very low quality

evidence. This remained unchanged based on removal of duplicate studies, EMT provider, manual chest

compressions, LMA use and laryngeal tube use (Table 5). When separated into low, moderate and serious risk

studies, the effect remained non-significant.

Insert Table 5 Here

Discussion:

This was the largest and most up to date systematic review and meta-analysis on airway management in OHCA,

with 29 studies and 539,146 patients included. Overall, ETT demonstrated better early survival rates (ROSC

and survival to admission) than SGA devices. Despite the improved early survival rates, there was no

significant in longer term outcomes such as survival to discharge and neurological function at discharge from

hospital. The clinical application of the overall improvements in early survival with the use of ETT is limited

due to the significant heterogeneity (I2=91%). This reflects the multifactorial nature of both cardiac arrest

aetiology and management. For this reason multiple sensitivity analyses were performed.

The first sensitivity analysis performed was to control for the skill level of care providers, thus an analysis

including EMT providers was undertaken. Again, the initial overall increase in early survival outcomes but not

survival to discharge or neurological state with ETT insertion remained. This sensitivity analysis still had

significant limitations such as, difference in seniority and skill level of EMT, indication and airway difficulty.

All of these factors directly impact on the success of the airway techniques, as well as, the expertise of the

provider managing the cardiac arrest as a whole [76]. Furthermore, the majority of studies did not report on

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intervention crossover rates, which would adversely affect time to successful ventilation, as well as delays to

chest compressions and other interventions. A further limitation to the overall results include large amount of

overlapping data from the same databases. When studies were assessed for duplication, eight overlapping

studies were identified. On sensitivity analysis, duplicate databases were removed which resulted in no change

the significance of the overall results, or the heterogeneity of the overall results.

Recommendations based on prior meta-analyses have been largely limited by the quality of included studies.

For the first time, the present study performed a sensitivity analysis based on low risk of bias RCTs. The

sensitivity analyses showed no difference between ETT and SGA in regard to ROSC (OR=0.90; 95%CI= 0.65

to 1.25; I2= 12%; p=0.59), survival to admission (OR= 1.00; 95%CI= 0.68 to 1.47; I2=0%; p=0.99), survival to

discharge (OR=0.90; 95%CI= 0.68 to 1.20; I2=70%; p=0.49) or neurological recovery at discharge (OR=0.88;

95%CI= 0.57 to 1.35; I2= 84%; p=0.55). All five studies were relatively homogenous utilizing non-physician

providers for the management of non-traumatic cardiac arrest. Three [53,65] of the five studies compared ETT

to LMA, whereas the studies by Wang et al and Rabitsch et alcompared ETT to esophagotracheal combitube

(ETC). Between the studies, the first attempt success rate for LMA (Supreme and I-gel) insertion was

reasonably consistent (75-79%). There was a higher than expected first attempt success rate for ETC 98% and

wide variation in ETT first attempt success rate (51-96%). Each of these studies appears to have controlled for

intra and post resuscitation care by following national guidelines. However, adherence to these guidelines is not

commented on. Notably, none of these studies included patients receiving automated chest compressions.

Therefore, these five RCTs serve as the first level 1 recommendation to show no difference in survival or

neurological outcome between ETT and SGA in advanced airway management for OHCA.

Further sensitivity analyses were performed in an attempt to control for specific intra-arrest management

variables. These included analyses of SGA device type and type of chest compression. Interestingly, the only

management related sensitivity analysis to show a significant benefit without heterogeneity was in the presence

of concurrent automated chest compressions. This is important given the increasing popularity of automated

compression devices for both in and out of hospital cardiac arrest [7,50]. This subgroup analysis was only able

to be performed on short term outcomes (ROSC and survival to admission).

Analyses of intrathoracic pressure during both manual and automated chest compressions have previously been

performed [77]. These show that there a greater sustained pressure throughout the chest compression cycle with

mechanical compressions[78]. However, compression induced ventilation is not possible in humans. Therefore,

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a patent airway and assisted ventilation is still required during cardiopulmonary resuscitation. The benefit of

ETT over SGA in this setting is likely related to elevated intrathoracic pressure and thus reduced efficacy of

SGAs. These findings suggest that if an emergency response service utilises automated compression devices,

endotracheal tubes are likely to result in increased survival. The one caveat to this suggestion is that when

mechanical compressions are used, the placement of an ETT will be more difficult. For this reason, airway

adjuncts such as the digitally-assisted pre-loaded bougie technique should be used[79,80].

Airway management is only one facet of intra and post cardiopulmonary resuscitation care. For this reason, it is

understandable why any difference in outcome will diminish over time. The results of the present study showed

no significant increase in survival to discharge or neurological outcome, with significant heterogeneity on all

subgroup analyses. This only serves to illustrate the complexity of post arrest neurological outcomes, beyond

simply avoiding hypoxia. Even in the most well designed RCT it would be difficult to control for key intra

arrest variables (e.g. cause of arrest [81], antiarrhythmic used [82]) or post arrest care (e.g. cooling [83], blood

pressure management [76]).

Limitations:

The predominant limitation to this review is the lack of RCTs and a significant number of retrospective studies

from overlapping databases. On the subgroup analysis removing the overlapping studies, this did not affect any

of the results. . This inconsistency of reported outcomes has been highlighted in critical care literature remains

a significant limitation to the conclusions drawn from the present study. Furthermore, the five RCTs utilized

different supraglottic airways, which may impact the overall outcome.

The diminishing effect of the overall result on longer term outcomes such as neurological status on discharge

likely reflects the multifactorial nature of arrest cause, provider type and management strategy. The majority of

studies included in the present review do not control for or even mention many variables such as antiarrhythmic

used and post ROSC management. This has a significant bearing on the conclusions drawn from the longer

term outcomes included in the present study.

Conclusion:

The present study showed a significant benefit with use of endotracheal intubation over supraglottic airway,

however this is likely the result of numerous other factors related to the cause and management of cardiac arrest.

Five low risk studies provide a generalised level one recommendation that overall there is no benefit for

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endotracheal intubation over supraglottic airway devices. In the situation of automated chest compressions

endotracheal intubation will likely result in an early survival benefit.

Conflict of Interest:

The authors have no conflicts of interest to declare.

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Figure 1: Study identification algorithm. This diagram outlines the filtering process from the literature search

through to study inclusion.

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Table 1: Study Characteristics

Study Study

Design

Sample

(ETT/SGA)

Cause of

OOHCA

SGA employed Registry

utilized (year)

Outcomes Risk of

Bias*

Becker et al

2017 [49]

Retrospective

Cohort

126 (84/42) All causes Not specified N/A 1. ROSC

2. Survival to admission

Serious

Benger et al

2016 [50]

RCT 615 (209/406) Non-traumatic i-Gel, LMA Supreme N/A 1. ROSC


3. Survival to discharge

Low

Benger et al

2018 [73]

RCT 9,296 (4,410/

4,886)

Non-traumatic i-Gel N/A 1. ROSC



2. Neurological outcome

Low

Bernhard et

al 2018 [7]

Retrospective

Cohort

22,350

(17,887/

4,363)

All causes Not specified German

Resuscitation

Registry

(2010-2016)

3. ROSC




Moderate

Cady et al

2009 [51]

Retrospective

Cohort

5,822

(4,335/1,437)

All causes Combitube N/A 1. ROSC



Serious

Chiang et al

2018 [52]

Retrospective

Cohort

4,640

(1,541/3,099)

Non-traumatic Not specified Utstein style

registry, Taipei

(2008-2013)

3. ROSC




Serious

Davey &

Dicker 2016

[53]

Retrospective

Cohort

965 (293/672) All causes Not specified St John New

Zealand

OHCA (2013-

2015)

1. ROSC

2. Survived to admission


Serious

Do Shin et

al 2012 [54]

Retrospective

Cohort

641 (250/391) Presumed

cardiogenic

aetiology

Not specified

Korea

nationwide

OHCA cohort

database

(2006-2008)



Moderate

Evans et al

2016 [55]

Retrospective

Cohort

1,555

(1,282/273)

Traumatic Not specified Resuscitation

Outcomes

Consortium

Epistry-

Trauma and

Prospective

Observational

Prehospital

and Hospital

Registry

(2005-2007 &

2010-2011)


Serious

Erath et al

2018 [74]

Propensity

Matched

Cohort

208 (160/48) All causes Laryngeal Tube N/A 1. Survival to admission


Moderate

Fukuda et al

2018 [6]

Retrospective

Cohort

132,874

(22,806/110,0

68)

All causes Not specified All Japan

Utstein

Registry

(2005-2014)



Moderate

Hanif et al Retrospective 1,158 All Causes Combitube or

oesophageal

N/A 1. ROSC


Moderate

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2010 [56] Cohort (1,027/131) obturator 3. Survival to discharge

Hasegawa &

Takei 2013

[57]

Retrospective

Cohort

281,522

(419,72/239,5

50)

All causes Not specified All-Japan

Utstein

Registry

(2005-2014)

1. ROSC



Serious

Jarman et al

2017 [58]

Prospective

Observational

316 (273/43) All causes King LT N/A 1. ROSC Moderate

Kajino et al

2011 [59]

Retrospective

Cohort

5,377

(1,679/3,698)

Non-traumatic Not specified Utstein style

Registry,

Osaka (2005-

2008)

1. ROSC




Serious

Kang et al

2015 [60]

Retrospective

Cohort

2,829

(1,634/1,195)

Non-traumatic Not specified Korea

nationwide

OHCA cohort

database

(2010-2013)

1. ROSC



Serious

Lin et al

2014 [61]

Retrospective

Cohort

1428

(1,384/44)

All causes Not specified Taiwan EMS

and hospital

registries

1. ROSC



Serious

McMullan et

al 2014 [62]

Retrospective

Cohort

8,701

(5,591/3,110)

All causes Not specified CARES

Registry

(2011)

1. ROSC




Moderate

Mulder et al

2013 [63]

RCT 188 (101/87) Non-traumatic LMA N/A 1. ROSC Low

Nagao et al

2012 [64]

Retrospective

Cohort

199 (10/189) All causes LMA and Combitube Utstein style

registry, Tokyo

(2006-2007)

1. ROSC Serious

Noda et al

2007 [65]

Retrospective

Cohort

28 (4/24) Cardiogenic

aetiology

LMA and Combitube Utstein style

registry,

Kyushu

University

Hospital

(2000-2006)

1. ROSC




Serious

Rabitsch et

al 2003 [66]

RCT 172 (83/89) Non-traumatic Combitube N/A 1. ROSC



Low

Sulzgruber

et al 2017

[67]

Propensity

Matched

Analysis

420 (210/210) All causes Not specified N/A 1. Survival to discharge


Moderate

Takei et al

2010 [68]

Prospective

Observational

948 (268/680) All causes

(cardiac and

non-cardiac

subgroups)

Not specified Utstein style

registry,

Ishikawa

(2004-2008)

1. ROSC



Serious

Tanebe et al

2013 [69]

Retrospective

Cohort

42,632

(12,992/

29,640)

Non-traumatic LMA and combitube All-Japan

Utstein

Registry

(2005-2007)

1. ROSC



Serious

Wang et al

2012 [70]

Secondary

analysis of

RCT data

10,425

(8,487/1,968)

Non-traumatic King laryngeal tube,

LMA and combitube

ROC PRIMED

Trial

1. Neurological outcome Serious

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Wang et al

2018 [75]

RCT 3,000 (1,495/

1,505)

Non-traumatic Laryngeal tube N/A 1. Survival to admission



Low

Yanagawa &

Sakamoto

2008 [71]

Retrospective 636 (158/478) All causes

(traumatic and

non-traumatic

subgroups)

Not specified Modified

Upstein style

registry,

Saitama(2006-

2007)

1. ROSC


Serious

Yeung et al

2014 [72]

Prospective

Observational

75 (50/25) All causes Marshall LMA (2008-2011) 1. ROSC


Serious

* Randomised controlled trials (RCTs) were assessed for risk of bias and methodological quality using the

Cochrane Collaboration’s tool for assessing the risk of bias [9]. Non-randomised were assessed using the

ROBINS-I tool [10]. ROSC= return of spontaneous circulation; OHCA= out-of-hospital cardiac arrest; ETT=

endotracheal tube; SGA= supraglottic airway; LMA= laryngeal mask airway; LT= Laryngeal Tube.

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Table 2: Association between endotracheal tube (ETT) intubation versus supraglottic airway (SGA) for return

of spontaneous circulation (ROSC) during cardiopulmonary resuscitation.

Group

Events/Total No of

patients

Risk Difference,

% (95%CI)

Relative Odds

ETT SGA Odds Ratio

(95%CI)

P Value I2%

All Studies

[6,7,49-73, 75]

18877/

95314

20942/

301844

0.05 (0.03 to

0.06)

1.44 (1.27 to

1.63)

<0.0000

1

91

Analysis After

Duplicate

Database

Removal

[6,7,49-58,60-

63,65-68,70,72,

73, 75]

17201/80

471

17835/26

3513

0.05 (0.03 to

0.08)

1.36 (1.20 to

1.54)

<0.0000

1

89

EMT provider

[7, 50-53,56-69,

71,72, 73, 75]

18847/

95149

20925/

301713

0.05 (0.03 to

0.07)

1.44 (1.28 to

1.63)

<0.0000

1

92

Manual Chest

Compressions

[7,49,51-

53,56,57-

69,71,72, 73, 75]

18144/

93604

20842/

301525

0.05 (0.03 to

0.06)

1.43 (1.26 to

1.62)

<0.0000

1

92

Automated

Chest

Compressions

[7,50]

733/

1710

100/ 319 0.10 (0.05 to

0.16)

1.55 (1.20 to

2.00)

0.0009 0

Laryngeal

Mask Airway

[49,52,53,63,72,

73]

1046/

6627

1452/

10526

0.06 (0.00 to

0.12)

1.43 (1.04 to

1.97)

0.03 86

Laryngeal Tube

[49,51,56,58,66,

67,75]

2272/

6936

1061/

3570

0.04 (0.00 to

0.08)

1.11 (0.88 to

1.40)

0.40 70

Low Risk

[50,63,66, 73,

75]

774/

6277

922/

6940

-0.02 (-0.08 to

0.04)

0.92 (0.80 to

1.05)

0.22 23

Moderate Risk

[7, 56, 58, 62,

67]

10531/24

419

2414/

8020

0.10 (0.07 to

0.13)

1.58 (1.43 to

1.74)

<0.0000

1

45

Serious Risk

[49,51-

7572/ 17606/ 0.04 (0.03 to 1.70 (1.42 to <0.0000 91

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54,57,59,60,68,6

9,71,72]

64618 286884 0.05) 2.02) 1

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EPTE

D M

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SCR

IPT

Table 3: Association between endotracheal tube (ETT) intubation versus supraglottic airway (SGA) for survival

to admission following cardiopulmonary resuscitation.

Group

Events/Total No of

patients

Risk Difference,

% (95%CI)

Relative Odds

ETT SGA Odds Ratio

(95%CI)

P Value I2%

All Studies

[7,49-

51,53,54,56,59

,62,65,66,

73,74]

11730/

33561

5235/

18195

0.05 (0.02 to

0.09)

1.36 (1.12 to

1.66)

0.002 91

Analysis

After

Duplicate

Database

Removal

[7,49-

51,53,54,56,59

,62,65,6673,

74]

11040/318

78

3819/1447

3

0.05 (0.02 to

0.10)

1.38 (1.10 to

1.72)

0.005 92

EMT

provider

[7,49,51,53,54,

56,59,62,65,

66, 73, 74]

11657/

33234

5206/

18016

0.06 (0.02 to

0.10)

1.41 (1.14 to

1.74)

0.0001 93

Manual Chest

Compressions

[7,49,51,53,54,

56,59,61,

62,65,66, 73,

74]

11254/

31849

5190/

17876

0.05 (0.01 to

0.09)

1.30 (1.06 to

1.61)

0.01 92

Automated

Chest

Compressions

[7,50]

476/ 1712 45/ 319 0.08 (-0.04 to

0.20)

2.16 (1.54 to

3.02)

<0.0000

1

0

Laryngeal

Mask Airway

[50,53,54,61,

73]

1078/2711

1580/5103

0.04 (-0.02 to

0.10)

1.23 (0.88 to

1.73)

0.23 81

Laryngeal

Tube

[49,51,56,66]

1346/5733 646/3181 0.03 (-0.03 to

0.08)

1.26 (0.82 to

1.93)

0.29 54

Low Risk 910/2207 -0.01 (-0.03 to 0.97 (0.86 to 0.59 0%

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[50,66, 73] 1122/2745 0.02) 1.09)

Moderate

Risk

[7,56,58,64,

68, 74]

8895/2491

5

1932/8143

0.09 (0.04 to

0.14)

1.61 (1.24 to

2.09)

0.0003 89

Serious Risk

[49,51,53,59,6

1,65]

1925/

6439

2181/

7307

0.05 (0.00 to

0.09)

1.30 (1.01 to

1.68)

0.04 75

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to discharge following cardiopulmonary resuscitation.

Group

Events/Total No

of patients

Risk Difference,

% (95%CI)

Relative Odds

ETT SGA Odds Ratio

(95%CI)

P

Value

I2%

All Studies [6,7,50-

57,59,61,62,65,67-

69,71, 73-75]

7826/

120274

13898/

320290

0.01 (0.00 to

0.02)

1.28 (1.02 to

1.60)

0.03 96

Analysis After

Duplicate Database

Removal [6,7,51-

57,59,61,62,65,67,5

8,71, 73-75]

7171/1

05599

12474/2

86928

0.01 (0.00 to

0.03)

1.33 (1.02 to

1.72)

0.03 97

EMT provider

[6,7,50-

57,59,61,62,65,67,6

8,69,71, 73-75]

7826/

120274

13898/

320290

0.01 (0.00 to

0.02)

1.28 (1.02 to

1.60)

0.03 96

Manual Chest

Compressions

[6,7,50-

57,59,61,62,65,67,6

8,69,71, 73-75]

7712/1

18646

13882/3

20013

0.01 (0.00 to

0.02)

1.28 (1.02 to

1.61)

0.04 96

Automated Chest

Compressions

N/A N/A N/A N/A N/A N/A

Laryngeal Mask

Airway [50,52-

54,61,72, 73]

595/67

94

682/108

59

0.03 (0.01 to

0.06)

1.80 (1.14 to

2.83)

0.01 85

Laryngeal Tube

[51,56,67, 75]

528/78

10

564/357

4

-0.02 (-0.14 to

0.09)

0.96 (0.32 to

2.90)

0.94 97

Low Risk [73, 75] 512/61

11

593/679

2

-0.01 (-0.03 to

0.02)

0.90 (0.68 to

1.20)

0.49 70

Moderate Risk

[6,7,54,56,62,67,74]

4243/4

8513

1917/31

352

0.03 (0.01 to

0.05)

1.54 (1.11 to

2.15)

0.01 92

Serious Risk [51-

53,55,57,59,61,65,6

8,69,72]

3071/

65650

11388/

282146

0.00 (-0.01 to

0.02)

1.34 (0.90 to

2.00)

0.15 97

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to discharge with a neurologically intact state following cardiopulmonary resuscitation.

Group

Events/Total No of

patients

Risk

Difference, %

(95%CI)

Relative Odds

ETT SGA Odds Ratio

(95%CI)

P

Value

I2%

All Studies

[6,7,52,57,69,60

,62,65,67,69-71,

73, 75

3853/

121006

4579/

317255

0.01 (0.00 to

0.01)

1.16 (0.94 to

1.41)

0.16 91

Analysis After

Duplicate

Database

Removal

[6,7,52,57,60,62

,67,70, 73, 75]

3628/1061

73

4130/2834

15

0.01 (0.00 to

0.02)

1.17 (0.92 to

1.49)

0.20 93

EMT provider

[6,7,52,57,59,60

,62,65,67,69-71,

73, 75]

3853/

121006

4579/

317255

0.01 (0.00 to

0.01)

1.16 (0.94 to

1.41)

0.16 91

Manual Chest

Compressions

[6,7,52,57,59,60

,62,65,67,69,70,

71, 73,75]

3773/1193

78

4569/

316978

0.01 (0.00 to

0.01)

1.15 (0.93 to

1.41)

0.20 91

Automated

Chest

Compressions

N/A N/A N/A N/A N/A N/A

Laryngeal

Mask Airway

[67, 73]

356/5948 397/7981 0.01 (0.00 to

0.01)

1.13 (0.95 to

1.33)

0.17 13

Laryngeal

Tube [70, 75]

162/2288 131/1904 0.01 (-0.06 to

0.08)

1.14 (0.41 to

3.17)

0.80 93

Low Risk [73,

75]

375/5902 418/6382 -0.01 (-0.03 to

0.02)

0.88 (0.57 to

1.35)

0.55 84

Moderate Risk

[6,7,62,67, 74]

2313/

47076

744/

30782

0.02 (-0.01 to

0.05)

1.46 (0.88 to

2.42)

0.15 96

Serious Risk

[52,55,59,60,65,

69,70,71]

1165/

68028

3417/

280091

0.00 (0.00 to

0.00)

1.06 (0.92 to

1.22)

0.41 51

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Figure 1

advanced airway management in out of hospital cardiac arrest: a …4f65350/uq4f... ·...

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