ALS 714: Advanced airway placement - Insertion of supraglottic airway
versus tracheal intubation
2010 Consensus on Science
Nine studies compared a variety of supraglottic airway devices with the tracheal
tube during cardiac arrest and a further 6 studies compared a variety of
supraglottic airway devices with the tracheal tube in patients undergoing
anesthesia. Overall in these studies the supraglottic airway device performed as
well as, or better than, the tracheal tube with respect to successful insertion
and/or time to tube insertion or to ventilation. One study retrospectively
compared outcomes in cardiac arrest patients treated with an esophagealtracheal-combitube or tracheal tube and found no difference in ROSC, survival to
admission, or survival to discharge. One study compared survival in cardiac
arrests managed with a laryngeal mask airway with an historical control group
of cardiac arrests managed with a tracheal tube and found that ROSC was
significantly higher in the study period (61% versus 36%). Eight manikin studies
with simulated cardiac arrest and 8 manikin studies without simulated cardiac
arrest showed that successful insertion rates and/or time to insertion or to
ventilation for a variety of supraglottic airway devices were as good, or better
than, for the tracheal tube.
Nine studies documented that when a supraglottic airway device is used as a
rescue airway after failed tracheal intubation, most patients can be ventilated
successfully with the supraglottic airway device. Two studies performed while
wearing anti-chemical protective clothing, one randomized crossover trial on
anesthetized patients, and a pseudorandomized study on manikins found
increased time to tracheal tube insertion but not to laryngeal mask airway
insertion.
Three manikin studies comparing a supraglottic airway device with the tracheal
tube during ongoing chest compressions demonstrated decreased time to
intubation with the supraglottic airway device, as well as reduced no flow time.
One nonrandomized manikin study found that chest compressions caused only a
minor increase in time to tracheal intubation but not to supraglottic airway
device insertion.
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PICO
Among adults who are in cardiac arrest in any setting (P), does supraglottic
airway insertion as first advanced airway (I), compared with insertion of a
tracheal tube as first advanced airway (C), change ROSC, CPR parameters,
development of aspiration pneumonia, survival with favourable
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 (O)?
Survival and favourable neurological outcome = Critical
ROSC = Important
CPR parameters = Important
Aspiration pneumonia = Low
PubMed/Embase/Cochrane Search on 19/12/13.
369 citations
350 excluded based on title and/or abstract review
19 reviewed in detail
2 articles were excluded – one RCT was in German and was not in fact a
randomised trial [Staudinger 1994 412]; one observational study relating to a
redundant device (EOA) and an unobtainable pdf [Hankins 1993, 117]
17 articles in final review 2 RCTs and 15 non-RCTs
After completion of bias reviews 4 studies were excluded because they reported
only blood gas data [Hammargen 1985 953 and Geehr 1985 381] or blood gas
and time to insertion data [Staudinger 1993 1573 and Bartlett 1992 280]
Data on ROSC are excluded from the Consensus on Science Statement when
longer-term survival data are available.
EGTA (I) versus tracheal intubation (C)
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For the critical outcome of survival to hospital discharge we have identified very
low quality evidence (downgraded for very serious concerns about risk of bias
and imprecision) from one RCT enrolling 175 OHCAs show no difference
between esophageal gastric tube airway (EGTA) 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 concerns about risk of bias,
inconsistency, indirectness and imprecision) from one 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 one
observational study of 5822 OHCAs that showed no difference between tracheal
intubation by paramedics and Combitube insertion by emergency medical
technicians (EMTs) (adjusted OR 1.02; 95% CI 0.79 -1.30) [Cady 2009 495].
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 concerns about risk of bias,
inconsistency, indirectness and imprecision) from one observational study of
641 OHCAs that showed lower rates of survival to hospital discharge with
insertion of an laryngeal mask airway (LMA) compared with tracheal tube (OR
0.69; 95% CI 0.4 – 1.3) [Shin 2012 313].
Supraglottic airways (SGAs: Combitube, LMA, laryngeal tube) versus
tracheal intubation
For the critical outcome of favourable neurological survival we have identified
very low quality evidence (downgraded for very serious concerns about risk of
bias, inconsistency and indirectness) from one 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 one
observational study of 281,522 OHCAs showing higher rates of favourable
neurological outcome between insertion of a SGA and tracheal intubation (OR
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1.11; 95% CI 1.0 – 1.2) [Hasegawa 2013 257] and from two studies showing
higher rates of favourable neurological outcome between tracheal intubation
and insertion of a 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]). The relative risk for the pooled data from these two studies
is
Supraglottic airways (SGAs: Combitube and LMA) versus tracheal
intubation
For the important outcome of ROSC we have identified very low quality evidence
(downgraded for very serious concerns about risk of bias, inconsistency,
indirectness and imprecision) from one observational study of 713 OHCAs that
showed no difference between tracheal intubation and Combitube or LMA
insertion by EMTs or emergency life-saving technicians (ELTs) (OR 0.65; 95% CI
0.4 – 1.2). [Yanagawa 2010 340].
Supraglottic airways (SGAs: Esophageal obturator airway and LMA) versus
tracheal intubation
For the critical outcome of neurologically favourable one-month survival we
have identified very low quality evidence (downgraded for very serious concerns
about risk of bias, inconsistency, indirectness and imprecision) from one
observational study of 138,248 OHCAs that showed higher rates of
neurologically favourable one-month survival with tracheal intubation compared
with insertion of an esophageal obturator airway or LMA (OR 0.89; 95% CI 0.8 –
1.0). [Tanabe 2013 389]
For the critical outcome of one-year survival we have identified very low quality
evidence (downgraded for very serious concerns about risk of bias,
inconsistency, indirectness and imprecision) from one observational study of
923 OHCAs that showed no difference in one-year survival with tracheal
intubation compared with insertion of an esophageal obturator airway or LMA
(OR 0.89; 95% CI 0.3 – 2.6). [Takei 2010 715].
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For the critical outcome of one-month survival we have identified very low
quality evidence (downgraded for very serious concerns about risk of bias,
inconsistency, indirectness and imprecision) from one observation study that
showed no difference in one-month survival between tracheal intubation and
insertion of an esophageal obturator airway of an LMA (OR 0.75; 95% CI 0.3 –
1.9) [Takei 2010 715] and very low quality evidence (downgraded for very
serious concerns about risk of bias, inconsistency, indirectness and imprecision)
from another observation study that showed higher one-month survival with
tracheal intubation compared with insertion of an esophageal obturator airway
of an LMA (OR 1.03; 95% CI 0.9 – 1.1) [Tanabe 2013 389]
Treatment recommendation
We suggest using either a supraglottic airway or tracheal tube as the initial
advanced airway management during CPR (weak recommendation, very low
quality evidence) for out of hospital cardiac arrest.
We suggest using either a supraglottic airway or tracheal tube as the initial
advanced airway management during CPR (weak recommendation, very low
quality evidence) for in hospital cardiac arrest.
Values and preferences

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 unrecognised oesophageal intubation and
increased hands off time in comparison with insertion of a supraglottic
airway.

Both a supraglottic airway 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.
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