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SGAs Versus Tracheal Intubation

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting  (P), does does SGA insertion as first advanced airway  (I), compared with compared with insertion of a tracheal tube as first advanced airway  (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, CPR parameters, development of aspiration pneumonia (O)?
Consensus on Science:
SGAs (Combitube, LMA, Laryngeal Tube) Versus Tracheal Intubation For the critical outcome of favorable neurologic survival, we have identified very-low-quality evidence (downgraded for very serious concerns about risk of bias, inconsistency, and indirectness) from 1 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 1 observational study of 281 522 OHCAs showing higher rates of favorable neurologic outcome between insertion of an SGA and tracheal intubation (OR, 1.11; 95% CI, 1.0–1.2)(Hasegawa 2013, 257) and from 2 studies showing higher rates of favorable neurologic outcome between tracheal intubation and insertion of an 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) SGAs (EOA and LMA) Versus Tracheal Intubation For the critical outcome of neurologically favorable 1-month survival, we have identified very-low-quality evidence (downgraded for very serious risk of bias, inconsistency, indirectness, and imprecision) from 1 observational study of 138 248 OHCAs that showed higher rates of neurologically favorable 1-month survival with tracheal intubation compared with insertion of an EOA or LMA (OR, 0.89; 95% CI, 0.8–1.0).(Tanabe 2013, 389) For the critical outcome of 1-month survival, we have identified very-low-quality evidence (downgraded for very serious concerns about risk of bias, inconsistency, indirectness, and imprecision) from 1 observational study that showed no difference in 1-month survival between tracheal intubation and insertion of an EOA of an LMA (OR, 0.75; 95% CI, 0.3–1.9)(Takei 2010, 716) and very-low-quality evidence (downgraded for very serious risk of bias, inconsistency, indirectness, and imprecision) from another observation study that showed higher 1-month survival with tracheal intubation compared with insertion of an EOA of an LMA (OR, 1.03; 95% CI, 0.9–1.1).(Tanabe 2013, 389) LMA (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 risk of bias, inconsistency, indirectness, and imprecision) from 1 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) Esophageal Gastric Tube Airway (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 risk of bias and imprecision) from 1 RCT enrolling 175 OHCAs showing no difference between esophageal gastric tube airway 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 risk of bias, inconsistency, indirectness, and imprecision) from 1 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 1 observational study of 5822 OHCAs that showed no difference between tracheal intubation by paramedics, and Combitube insertion by emergency medical technicians (adjusted OR, 1.02; 95% CI, 0.79–1.30).(Cady 2009, 495)
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. Values, Preferences, and Task Force Insights In the absence of sufficient data obtained from studies of IHCA, it is necessary to extrapolate from data derived from OHCA. 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 unrecognized esophageal intubation and increased hands off time in comparison with insertion of an SGA. Both an SGA 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.
CoSTR Attachments:
ALS 714 CoS and TR for SGA versus TT_JN_EL_PM_21Dec14_1.doc    
ALS 714 CoS and TR for SGA versus TT_JN_EL_PM_21Dec14_2.doc    
ALS 714 Evidence Profile for SGA versus TT_Part 1_JN_EL_21Dec14_1.doc    
ALS 714 Evidence Profile for SGA versus TT_Part 2_JN_EL_21Dec14_1.doc    
ALS 714 Evidence Profile for SGA versus TT_Part 3_JN_EL_21Dec14_1.doc    
ALS 714 Summary of Bias Assessments for SGA versus TT5_1.xls    

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