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Basic Versus Advanced Airway

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting  (P), does does insertion of an advanced airway (tracheal tube or SGA)  (I), compared with compared with basic airway (bag-mask device with or without oropharyngeal 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:
All Advanced Airways (I) Versus Bag-Mask Device (C) For the critical outcome of 1-year survival, we have identified very-low-quality evidence (downgraded for very serious risk of bias, indirectness and imprecision, and serious inconsistency) from 1 observational study of 1278 OHCAs showing a similar unadjusted rate of survival with insertion of an advanced airway (tracheal tube, esophageal obturator airway [EOA] or laryngeal mask airway [LMA]) compared with a bag-mask device (3.7% versus 5.6%; OR, 0.65; 95% CI, 0.4–1.1).(Takei 2010, 716) For the critical outcome of favorable neurologic survival at 1 month, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness and serious inconsistency) from 1 observational study of 648 549 OHCAs showing a lower unadjusted rate of survival with insertion of an advanced airway (tracheal tube, LMA, laryngeal tube, or Combitube) compared with management with a bag-mask device (1.1% versus 2.9%; OR, 0.38; 95% CI, 0.36–0.39).(Hasegawa 2013, 257) When adjusted for all known variables, the OR was 0.32 (95% CI, 0.30–0.33). For the critical outcome of favorable neurologic survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 1 observational study of 10 691 OHCAs showing a lower unadjusted rate of survival with insertion of an advanced airway (tracheal tube, LMA, laryngeal tube, or Combitube) compared with management with a bag-mask device (5.3% versus 18.6%; OR, 0.25; 95% CI, 0.2–0.3).(McMullan 2014, 617) In an analysis of 3398 propensity-matched patients from the same study, the OR for favorable neurologic survival at hospital discharge (bag-mask device versus advanced airway) adjusted for all variables was 4.19 (95% CI, 3.09–5.70). For the critical outcome of survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 2 observational studies: 1 of 10 691 OHCAs showed a lower unadjusted rate of survival with insertion of an advanced airway (tracheal tube or LMA) compared with a bag-mask device (7.7% versus 21.9%; OR, 0.30; 95% CI, 0.3–0.3)(McMullan 2014, 617-622); 1 of 5278 OHCAs showed a similar unadjusted rate of survival with insertion of an advanced airway (tracheal tube or LMA) compared with a bag-mask device (6.6% versus 7.0%; OR, 0.94; 95% CI, 0.7–1.3).(Shin 2012, 313) Tracheal Intubation (I) Versus Bag-Mask Device (C) For the critical outcome of favorable neurologic survival at 1 month, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 1 observational study of 409 809 OHCAs showing a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (1.0% versus 2.9%; OR, 0.35; 95% CI, 0.31–0.38).(Hasegawa 2013, 257) In an analysis of 357 228 propensity-matched patients from the same study, the OR for favorable neurologic survival at 1 month (tracheal intubation versus bag-mask device) adjusted for all variables was 0.42 (95% CI, 0.34–0.53). For the critical outcome of survival at 1 month, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 2 observational studies. One of 409 809 OHCAs showed a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (4.2% versus 5.3%; OR, 0.77; 95% CI, 0.74–0.81).(Hasegawa 2013, 257) In an analysis of 357 228 propensity-matched patients from the same study, the OR for survival at 1 month (tracheal intubation versus bag-mask device) adjusted for all variables was 0.88 (95% CI, 0.79–0.98). Another study of 10 783 OHCAs also showed a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (3.6% versus 6.4%; OR, 0.54; 95% CI, 0.5–0.7).(Holmberg 2002, 37) For the critical outcome of favorable neurologic survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 1 observational study of 7520 OHCAs showing a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (5.4% versus 18.6%; OR, 0.25; 95% CI 0.2–0.3).(McMullan 2014, 617) For the critical outcome of survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias, indirectness, and imprecision, and serious inconsistency) from 6 observational studies. One observational study of 7520 OHCAs showing a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (8.3% versus 21.9%; OR, 0.25; 95% CI, 0.2–0.3).(McMullan 2014, 617) One study of 4887 OHCAs showed a similar unadjusted rate of survival with insertion of a tracheal tube compared with a bag-mask device (8.0% versus 7.0%; OR, 1.16; 95% CI, 0.7–1.9).(Shin 2012, 313) Among 496 propensity-matched OHCAs in the same study, the OR for survival to discharge (tracheal intubation versus bag-mask device) was 1.44 (95% CI, 0.66–3.15).(Shin 2012, 313) One observational study of 1158 OHCAs showed a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (3.7% versus 10.8%; OR, 0.32; 95% CI, 0.2–0.6).(Hanif 2010, 926) One observational study of 8651 OHCAs showed a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (3.7% versus 9.1%; OR, 0.41; 95% CI, 0.3–0.5).(Adams 1997, 399) One observational study of 1142 OHCAs showed a lower unadjusted rate of survival with tracheal intubation compared with a bag-mask device (6.3% versus 28.6%; OR, 0.17; 95% CI, 0.1–0.2).(Studnek 2010, 918) Supraglottic Airways (I) Versus Bag-Mask Device (C) For the critical outcome of favorable neurologic survival at 1 month, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 1 observational study of 607 387 OHCAs showing a lower unadjusted rate of survival with insertion of an SGA (LMA, laryngeal tube, or Combitube) compared with a bag-mask device (1.1% versus 2.9%; OR, 0.38; 95% CI, 0.37–0.40).(Hasegawa 2013, 257) In an analysis of 357 228 propensity-matched patients from the same study, the OR for favorable neurologic survival at 1 month (SGA versus bag-mask device) adjusted for all variables was 0.36 (95% CI, 0.33–0.40). For the critical outcome of favorable neurologic survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency) from 1 observational study of 5039 OHCAs showing a lower unadjusted rate of survival with an SGA compared with a bag-mask device (5.2% versus 18.6%; OR, 0.24; 95% CI, 0.2–0.3).(McMullan 2014, 617) For the critical outcome of survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias, indirectness, and imprecision, and serious inconsistency) from 2 observational studies. One observational study of 5039 OHCAs showed a lower unadjusted rate of survival with an SGA compared with a bag-mask device (6.7% versus 21.9%; OR, 0.26; 95% CI, 0.2–0.3).(McMullan 2014, 617) Another study of 262 OHCAs also showed a lower unadjusted rate of survival with an SGA compared with a bag-mask device (0.0% versus 10.7%).(Hanif 2010, 926) Laryngeal Mask Airway (I) Versus Bag-Mask Device (C) For the critical outcome of survival to hospital discharge, we have identified very-low-quality evidence (downgraded for very serious risk of bias, indirectness, and imprecision, and serious inconsistency) from 1 observational study of 5028 OHCAs showing a similar unadjusted rate of survival with insertion of an LMA compared with a bag-mask device (5.6% versus 7.0%; OR, 0.80; 95% CI, 0.5–1.2).(Shin 2012, 313-319) Among 772 propensity-matched OHCAs in the same study, the OR for survival to discharge (LMA versus bag-mask device) was 0.45 (95% CI, 0.25–0.82).(Shin 2012, 313)
Treatment Recommendation:
We suggest using either an advanced airway or a bag-mask device for airway management 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 may result in unrecognized esophageal intubation and increased hands-off time in comparison with insertion of an SGA or a bag-mask device. Both a bag-mask device and an advanced airway are frequently used in the same patient as part of a stepwise approach to airway management, but this has not been formally assessed.
CoSTR Attachments:
ALS 783 CoS and TR for basic versus advanced 10Jan15_1.doc    
ALS 783 Evidence profile any advanced airway versus Basic_10Jan15_1.doc    
ALS 783 Evidence Profile SGA versus Basic_10Jan15_1.doc    
ALS 783 Evidence Profile Tracheal intubation versus basic_10Jan15_1.doc    
Summary of Bias Assessments for Basic versus Advanced 14Dec14_1.xls    

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