Dallas 2015 TFQO: Jerry Nolan #310 EVREV 1: Jerry Nolan COI #301 EVREV 2: Jan-Thorsten Graesner COI #150 Taskforce: ALS ALS 783 : Advanced versus basic airway

Dallas 2015 COI Disclosure Jerry Nolan COI #310 Commercial/industry Editor-in-Chief Resuscitation Potential intellectual conflicts Co-applicant AIRWAYS-2 (igel versus intubation) NIHR Funded Jan-Thorsten Graesner COI #150 Commercial/industry Potential intellectual conflicts

Dallas TR A supraglottic airway device may be considered by healthcare professionals trained in its use as an alternative to bag- mask ventilation during cardiopulmonary resuscitation.

Dallas 2015 C2015 PICO Population: patients in cardiac arrest in any setting Intervention: Insertion of an advanced airway (ETT or SGA) Comparison: Basic airway (bag mask +/- oropharyngeal airway) Outcomes: Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year (9-Critical) Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year (8-Critical) Change ROSC, CPR parameters, aspiration pneumonia

Dallas 2015 Inclusion/Exclusion & Articles Found The search yielded a total of 242 studies. Of these, 5 studies were included in bias assessment but 2 were excluded because they provided no survival data 8 additional studies found not included in search (one published since search) 2 studies (Takei and Nagao) likely to have been included in larger study (Hasegawa) and therefore excluded 11 studies included in final review

Dallas 2015 Risk of Bias in non-RCTs

Any Advanced Airway versus Basic Airway

Tracheal intubation versus Basic airway

SGA versus Basic Airway

Dallas 2015 Proposed Consensus on Science statements All advanced airways (I) versus bag-mask (C) For the critical outcome of favourable neurological survival at one month we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and indirectness, and serious concerns about inconsistency) from one observational study of OHCAs showing a lower unadjusted rate of survival with insertion of an advanced airway (tracheal tube, LMA, LT or Combitube) compared with management with a bag-mask (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, )) [Hasegawa ]. When adjusted for all known variables the odds ratio was 0.32 ( ). For the critical outcome of favourable neurological survival to hospital discharge we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and indirectness, and serious concerns about inconsistency) from one observational study of OHCAs showing a lower unadjusted rate of survival with insertion of an advanced airway (tracheal tube, LMA, LT or Combitube) compared with management with a bag-mask (5.3% vs 18.6%; odds ratio [OR], 0.25; 95% CI, 0.2 – 0.3)) [McMullan ]. In an analysis of 3398 propensity-matched patients from the same study, the odds ratio for favourable neurological survival at hospital discharge (bag-mask versus advanced airway) adjusted for all variables was 4.19 (3.09 – 5.70).

Dallas 2015 Proposed Consensus on Science statements Tracheal intubation (I) versus bag-mask (C) For the critical outcome of favourable neurological survival at one month we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and indirectness, and serious concerns about inconsistency) from one observational study of OHCAs showing a lower unadjusted rate of survival with tracheal intubation compared with management with a bag-mask (1.0% vs 2.9%; OR 0.35 ( )) [Hasegawa ]. In an analysis of propensity-matched patients from the same study, the odds ratio for favourable neurological survival at one month (tracheal intubation versus bag-mask) adjusted for all variables was 0.42 (0.34 – 0.53). For the critical outcome of favourable neurological survival to hospital discharge we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and indirectness, and serious concerns about inconsistency) from one observational study of 7520 OHCAs showing a lower unadjusted rate of survival with tracheal intubation compared with management with a bag-mask (5.4% vs 18.6%; odds ratio [OR], 0.25; 95% CI, 0.2 – 0.3)) [McMullan ].

Dallas 2015 Proposed Consensus on Science statements Supraglottic airways (I) versus bag-mask (C) For the critical outcome of favourable neurological survival at one month we have identified very low quality evidence (downgraded for very serious concerns about risk of bias and indirectness, and serious concerns about inconsistency) from one observational study of OHCAs showing a lower unadjusted rate of survival with insertion of a supraglottic airway (LMA, LT or Combitube) compared with management with a bag-mask (1.1% vs 2.9%; OR 0.38 ( )) [Hasegawa 2013]. In an analysis of propensity-matched patients from the same study, the odds ratio for favourable neurological survival at one month (supraglottic airway versus bag-mask) adjusted for all variables was 0.36 ( ).

Dallas 2015 Draft Treatment Recommendations We suggest using either an advanced airway or a bag mask for airway management during CPR (weak recommendation, very low quality evidence) for out of hospital cardiac arrest.

Dallas 2015 Values and preferences In the absence of sufficient data obtained from studies of in- hospital cardiac arrest, it is necessary to extrapolate from data derived from out of hospital cardiac arrest. The type of airway used may depend on the skills and training of the healthcare provider. Tracheal intubation may result in unrecognised oesophageal intubation and increased hands off time in comparison with insertion of a supraglottic airway or a bag mask Both a bag mask and an advanced airway are frequently used in the same patient as part of a stepwise approach to airway management but this has not been formally assessed.

Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date