JOURNAL CLUB

Omar Albaroudi, MD
Emergency Medicine Residency Training Program
Hamad Medical Corporation
 I have no conflict of interest
or disclosure in relation to this presentation
EVERY DAY STORY
• Bay-1
• Patient arrested
• Chest compressions initiated
• Intubation done immediately

interruption of chest compressions

hyperventilation
hyperoxia
TO INTUBATE OR NOT TO INTUBATE
LITTLE IS KNOWN
• Mortality after adult in-hospital cardiac arrest remains
high
• Little is known about the effect of most interventions
• Over the past few years there has been a shift from ABC
to CAB
• 2015 guidelines of both the American Heart Association
and the European Resuscitation Council state that either
a bag-valve-mask device or an advanced airway during
cardiac arrest
 Not to intubate
• Hasegawa K, Hiraide
A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurol
ogic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013; 309:257
.
Prospective Japanese study involving 649,359 patients, the rate of survival with a favorable
neurologic outcome was significantly lower among those managed with advanced airway
techniques compared with bag-mask ventilation (1.1 versus 2.9 percent; odds ratio [OR] 0.38,
95% CI 0.36-0.39)
• McMullan J, Gerecht R, Bonomo
J, et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registr
y. Resuscitation 2014; 85:617.
Retrospective review of registry data involving 10,691 cardiac arrest patients, which reported
that patients managed in the prehospital setting with bag-mask ventilation had significantly
higher rates of neurologically intact survival to hospital discharge than patients managed with
either a supraglottic airway or intubation (18.6 versus 5.2 percent and 5.4 percent,
respectively)
To intubate
• Kang K, Kim T, Ro YS, Kim YJ, Song KJ, Shin SD. Prehospital endotracheal
intubation and survival after out-of-hospital cardiac arrest: results from the Korean
nationwide registry. Am J Emerg Med. 2016;34(2):128-132.
• …
 Objectives
Introduction
Study summary
Critical appraisal
Relevance to EM practice
Association Between Tracheal Intubation
During Adult In-Hospital Cardiac Arrest and Survival
• Multicentre, observational, retrospective, propensity-
matched, cohort study

• 14 years: Jan/2000 – Dec/2014

• US-based multicentre registry of in-hospital cardiac arrest

from 668 hospitals

 PICO
• Population

108,079 Patients >18yr who had an in-hospital cardiac arrest from Jan-
2000 to Dec-2014 in 668 hospitals
• Intervention (Exposure)

Patients who intubated at any given minute (from 0-15 minutes)

• Comparison (Control)

Patients at risk of being intubated within the same minute

• Outcome

Primary outcome was survival to hospital discharge

Secondary outcomes: ROSC, good functional outcome (CPC 1-2)
• Inclusion criteria

Adult patients (aged ≥ 18 years) with an index cardiac arrest for

which they received chest compressions
• Exclusion criteria

- Patients who had an invasive airway in place at the time of the

cardiac arrest (including tracheal tube, tracheostomy, laryngeal mask
airway, or other invasive airways but not including nasopharyngeal or
oropharyngeal airways)
- Hospital visitors and employees
- Patients with missing data (tracheal intubation, covariates except race,
and survival)
70%
 Statistical Analysis
• Propensity score matching

(mimic randomization!)
time-dependent

• 86 628 patients were included in the propensity matched cohort

43 314 intubated patients matched 1:1 to 43 314 patients

without intubation during the same minute
(although these patients could have been intubated later)
 Study results
• Primary outcome

Survival was lower among patients who were intubated compared with
those not intubated
• Secondary outcome

The proportion of patients with ROSC was lower among intubated

patients than those not intubated
Good functional outcome was also lower among intubated patients than
those not intubated
P <0.001
Author conclusion
Among adult patients with in-hospital cardiac arrest,
initiation of tracheal intubation within any given minute
during the first 15 minutes of resuscitation, compared
with no intubation during that minute, was associated
with decreased survival to hospital discharge.
Although the study design does not eliminate the
potential for confounding by indication, these findings do
not support early tracheal intubation for adult in-hospital
cardiac arrest.
Critical Appraisal
Are the results valid?
What are the results?
Will it apply locally?
PICO
• Clearly defined population, intervention, and outcomes

• Cardiac arrest is defined as pulselessness requiring chest compressions and/or

defibrillation, with a hospital-wide or unit-based emergency response
• Tracheal intubation was defined as insertion of a tracheal or tracheostomy tube
during the cardiac arrest.
• ROSC was defined as no further need for chest compressions (including
cardiopulmonary bypass) sustained for at least 20 minutes.
 Were the cohorts similar?
• Are the differences important?
• Were they adjusted?

• Residual confounders?
• skills and experience of health care professionals
• underlying cause of the cardiac arrest
• quality of chest compressions
• indication for intubation
• unsuccessful intubation attempts
Bias?
• Blindness?

Abstractors assessing outcomes were not blinded to exposure

status, but were unaware of the hypothesis of the current study
• Conflict of interest?
Follow-up
• Long enough?

• Lost to flow-up?
IN NUMBERS
• Risk Ratio = 0.84 (95% CI = 0.81-0.87)

Strong association?
Accurate?

• Absolute “Survival” Reduction = 19.4-16.3 = 3.1%

In the ED
• Risk Ratio = 0.79 (0.73-0.85)

• Absolute “Survival” Reduction = 25.6-20.1 = 5.5%

Will it apply locally?
• Local population?
• Local setting?
Discussion