What’s the Optimal Timing for Advanced Airway Placement in OHCA?

?Why does this matter
Everyone learns their ABCS, including prehospital providers. While an advanced airway is often prioritized in OHCA, chest compressions are likely what matter most. If the timing of airway placement after ACLS initiation was shown to change survival, it would change protocols for many EMS crews. Does timing matter?

?Early bird gets the worm or better late than never
This was a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART). In both the laryngeal tube group (n=1,091) and the endotracheal intubation group (n=1,055), timing of airway insertion after initiation of advanced life support was explored using propensity score matching: 0-5 minutes, 5-10 minutes, 10-15 minutes, 15-20 minutes, and >20 minutes.

There was no association with survival to hospital discharge found in either airway group for any time to airway placement quartile (See table).

The original intent of the PART was to determine if an endotracheal tube vs supraglottic airway was associated with better outcomes in patients who suffered OHCA. The original study favored the supraglottic airway in multiple outcomes, including survival. In this secondary analysis, it doesn’t seem like timing matters much if you can effectively provide chest compressions and bag the patient. My take would be to inform my EMS crews to place a supraglottic when convenient after arrival, with the priority being high quality CPR and assessment for a shockable rhythm.

Source
Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2021 Sep 15;S0196-0644(21)00695-8. doi: 10.1016/j.annemergmed.2021.07.114. Online ahead of print.