For patients having a heart attack outside the hospital, advanced techniques (such as inserting a tube into the trachea or a “supraglottis airway device” into the throat above the larynx) are considered the gold standard for providing an open airway to ensure the body continues to get oxygen. But research appearing today in JAMA suggests patients treated with these advanced techniques may have an increased risk of poorer neurological outcomes compared with patients who receive conventional bag-valve-mask ventilation.
The study involved 649 654 consecutive adult patients in Japan who had an out-of-hospital heart attack and received resuscitation attempts by emergency responders, 57% of whom received bag-valve-mask ventilation and 43% of whom received advanced airway management. About 5% of those receiving bag-valve-mask ventilation were alive 1 month later, compared with 3.9% of those receiving advanced airway management. In addition, a little more than half of those who received bag-valve-mask ventilation and survived had favorable neurologic function compared with a little more than one-quarter of survivors who had advanced airway management.
Lead author Kohei Hasegawa, MD, MPH, of Massachusetts General Hospital and Harvard Medical School, Boston, discusses his team’s findings.
news@JAMA: What prompted you to do this study?
Dr Hasegawa: My research is on emergency airway management and cardiac arrest, and we knew from several small studies that there may be an issue regarding neurologic function with more aggressive treatment. So we did this larger study.
news@JAMA: Your results go against conventional wisdom. Isn’t “advanced” airway treatment better than conservative treatment?
Dr Hasegawa: There is a popular belief that advanced airway management is better, but we show a contradiction.
news@JAMA: So should bag-valve-mask ventilation be the airway management of choice?
Dr Hasegawa: Maybe, but we don’t know for sure. Any observational study cannot show causality. Good neurological outcome does not prove the causality.
news@JAMA: Should first responders abandon advanced airway management for people having a heart attack outside the hospital?
Dr Hasegawa: I cannot say that we have to change the practice right now, but we have to think about it. And we have to be careful for unintended consequences. Intubation is a very difficult skill to learn and retain. If we abandon it, will we have untrained people put in positions where such intubation is required?
news@JAMA: What does the research community need to do next?
Dr Hasegawa: We need to take the next step and run controlled trials, which are very difficult to do [in emergency situations]. In our study, we basically found equipoise exists, which means we don’t know the answers as to how best to manage airways in these patients.