COMPARATIVE STUDY
JOURNAL ARTICLE
MULTICENTER STUDY

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Lars W Andersen, Asger Granfeldt, Clifton W Callaway, Steven M Bradley, Jasmeet Soar, Jerry P Nolan, Tobias Kurth, Michael W Donnino
JAMA: the Journal of the American Medical Association 2017 February 7, 317 (5): 494-506
28118660

Importance: Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.

Objective: To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

Design, Setting, and Participants: Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

Exposure: Tracheal intubation during cardiac arrest.

Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.

Results: The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

Conclusions and Relevance: 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.

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Terren Trott

Very important study highlighting some of the potential errors that occur when intubating during an arrest. While this study does demonstrate a patient-centered outcome difference (mortality and neurologic status) preferring non-intubation, the limitations of a retrospective registry study can't be ignored. A prospective trial comparing intubation and non-intubation has yet to be done. However there is no qualm with the take home points of:

Intubation may lead to prolonged interruption in compressions
Intubation may lead to hyperventilation and hyperoxia
Intubation may delay interventions such as defibrillation and epinephrine
Delays to intubation will prevent oxygenation by other means
Unrecognized esophageal intubations can lead to fatal outcomes

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