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Original Investigation
August 28, 2018

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial

Author Affiliations
  • 1University of the West of England, Glenside Campus, Bristol
  • 2South Western Ambulance Service NHS Foundation Trust, Exeter, England
  • 3Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, England
  • 4Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, England
  • 5Bristol Medical School, University of Bristol, Bristol, England
  • 6Department of Anaesthesia, Royal United Hospital, Bath, England
  • 7CLAHRC West, Whitefriars, Bristol, England
  • 8Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England
  • 9Intensive Care Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, England
JAMA. 2018;320(8):779-791. doi:10.1001/jama.2018.11597
Key Points

Question  Does an initial strategy of a supraglottic airway device for advanced airway management during nontraumatic out-of-hospital cardiac arrest result in a better functional outcome compared with tracheal intubation?

Findings  In this cluster randomized clinical trial that included 1523 paramedics and 9296 patients with out-of-hospital cardiac arrest, favorable functional outcome (modified Rankin Scale score in 0-3 range) at hospital discharge or after 30 days (if still hospitalized) occurred in 6.4% of patients in the supraglottic airway group vs 6.8% of patients in the tracheal intubation group, a difference that was not statistically significant.

Meaning  In this study, a strategy of using a supraglottic airway device for advanced airway management did not provide a superior functional outcome.


Importance  The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.

Objective  To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.

Design, Setting, and Participants  Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.

Interventions  Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.

Main Outcomes and Measures  The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.

Results  A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], −0.6% [95% CI, −1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, −0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, −1.5% to 1.8%]).

Conclusions and Relevance  Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.

Trial Registration  ISRCTN Identifier: 08256118