Advanced airway management in adult out-of-hospital cardiac arrest

Abstract

Abstract Introduction: Recently published trials comparing airway management in out-of-hospital cardiac arrest did not show any superiority of tracheal intubation (TI) over other airway management strategies. This was followed by a change in the resuscitation guidelines to restrict the use of TI to healthcare providers with a success rate of 95% or higher within two attempts. Therefore, this thesis explores the changes in the policies and practices following these results, the available evidence concerning emergency front-of-neck access (eFONA) in the cases where TI is limited, and the impact of airway management on the quality of resuscitation. Methods: I performed a cross-sectional survey to examine the changes in the polices concerning the use of TI among ambulance services. To examine the impact of the AIRWAYS-2 trial, I performed a retrospective cohort study utilising logistic, segmented, and Joinpoint regression, and I performed a scoping review to examine the breadth of literature concerning eFONA in cardiac arrest. I also conducted a systematic review to understand the impact of airway management on resuscitation quality. Results: This thesis captures the key new information that several ambulance services withdrew TI from non-specialist paramedics due to several causes, especially the AIRWAYS-2 trial. The use of TI decreased over time (adjusted odds ratio 0.938, 95% confidence interval 0.936-0.941), particularly following the publication of AIRWAYS-2. In addition, the estimated percentage decrease in the use of TI per quarter was lower before the publication of AIRWAYS-2 (‑0.021, 95% CI ‑0.023 to ‑0.019) than following the publication of AIRWAYS-2 (‑2.01, 95% CI ‑2.04 to ‑1.99). The previously mentioned results add to the existing knowledge that major studies impact the clinical practice in the OHCA field. In addition, this thesis provides key new information that no research paper has focused on eFONA in cardiac arrest. Moreover, the available evidence showed that the use of eFONA in cardiac arrest is a suitable choice in situations where patients cannot be intubated or cannot be ventilated. In addition, the new key information captured showed that airway management impacts resuscitation quality. Increased chest compression fraction in

advanced airway management compared with basic airway management was captured. However, other quality metrics varied among different airway devices used. Conclusion: The use of TI is decreasing while the use of supraglottic airway is on the rise in OHCA. Additionally, eFONA is suitable for cases where intubation and ventilation are not possible. When considering advanced airway management, it is important to emphasise the quality of resuscitation.