Timing of intubation for in hospital cardiac arrest ?

Traditional wisdom taught us to secure airway as soon as possible in case of cardiac arrest(at least in hospital arrest), though over the course of years, American hearth association have moved their focus from “ABC” (airway-breathing-circulation) to “CAB” (circulation-airway-breathing). AHA also suggested that if a trained individual is not present to secure airway, bag mask ventilation was alternative. 2015 guidelines suggest either approach (bag mask or intubation) is acceptable.

Lars  Andersen,  Asger Granfeldt, Clifton W. Callaway et al published in JAMA on 24th January, 2017 about timing of tracheal intubation in cardiac arrest in hospitalized patients.

WHAT

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.  Looking at the timing of tracheal intubation and outcome.

FINDINGS

Total of 108 079 adult patients at 668 hospitals were studied.

71 615 patients (66.3%) who were intubated within the first 15 minutes were matched to 43 314 patients (60.5%)  not intubated within first 15 minutes.

Survival (RR = 0.84), ROSC (RR = 0.97), and good functional outcome (RR = 0.78) were lower in patients who were intubated within 15 minutes of cardiac arrest.

 

STRENGTH OF STUDY

Large patient pool and detailed data, rich of information.

 

SUBGROUP ANALYSIS

Patients with shockable rhythm and without pre-existing respiratory insufficiency, did poor if intubated earlier.

 

POSSIBLE EXPLANATIONS FOR THE RESULTS

  1. Distraction from effective chest compressions
  2. Primary therapy delayed ( shock in shockable patients)
  3. Higher oxygen concentrations to intubated patients
  4. Earlier intubated patients had greater illness severity
  5. Those who were intubated received aggressive care(May be harmful!)

BOTTOMLINE

Early intubation during in-hospital cardiac arrest may  be harmful, and clear demonstration of benefit is lacking.