The Resuscitation Effects Of Endotracheal Intubation Versus Supraglottic Airway Placement In Out-of-Hospital Cardiac Arrest:A Meta-Analysis

Objective: Interventions performed by Emergency Medical Services System(EMSS)prior to Emergency Department arrival have a pivotal impact on patient outcomes after out-of-hospital cardiac arrest(OHCA).Airway management via bag-valve mask,endotracheal intubation(ETI),or supraglottic airway(SGA),is a key component of resuscitation,as it may reverse the hypoxia and hyper-carbia of cardiac arrest.Optimal airway management during out-of-hospital cardiac arrest is still controversial.The current guideline recommendations are based on observational studies and expert consensus.There is a lack of data from high-quality study.Advanced airway management after initial bag-valve mask ventilation,such as endotracheal intubation(ETI),or supraglottic airway(SGA),is a fundamental component of resuscitation.The objective of this meta-analysis is to compare the patient outcomes of these two advanced airway methods in OHCA patients treated by emergency medical services system(EMSS).Methods: Databases such as PubMed,Embase,Cochrane Database and Scopus were searched to identify all relevant peer-reviewed articles for inclusion from the establishment of the library until September 2018 in the meta-analysis.Literature screening was performed in accordance with the inclusion and exclusion criteria.The literature was screened and managed by the End Note software.The quality of the included studies was independently evaluated according to the Cochrane Quality Rating Scale and the Newcastle Ottawa Scale(NOS).This study used the Cochrane scale to evaluate the RCTs;the Cochrane scale assessed the generation of random sequences,randomized concealment,blinding,and the description of outcomes.The NOS scale was used for the cohort studies;it included the selection of the cohort,the comparability between groups.The primary outcomes were(1)return of spontaneous circulation(ROSC),(2)survival to hospital admission,(3)survival to hospital discharge,and(4)neurologically intact survival to hospital discharge.The secondary outcome was complications associated with ETI and SGA,which included reguigitation and aspiration After quality evaluation was performed,we used Rev Man 5.3 software to conduct sensitivity analysis and heterogeneity analysis.Results were adjusted for covariates when available and combined using the random effects model or fixed effects model.Results: From 4,597 titles,15 observational studies and 1 randomized clinical trial fulfilled all criteria,representing 41,635 ETI patients and 50,868 SGA patients.Important covariates were similar between groups.Patients who received ETI had statistically significant higher odds of ROSC(RR=1.21,95%CI 1.09~1.34,P=0.0002),survival to hospital admission(RR=1.18,95%CI 1.04~1.33,P=0.008)and neurologically intact survival to hospital discharge(RR=1.10,95%CI1.02~1.19,P=0.02)compared to SGA.Survival to hospital discharge was not statistically different(RR=1.11,95%CI 0.98~1.26,P=0.10).Only one study reported the complications(reguigitation and aspiration)associated with ETI and SGA,two of the secondary outcomes were not significangtly different between groups.Conclusion: Patients with OHCA who receive ETI by EMSS are more likely to achieve ROSC,survive to hospital admission and neurologically intact survival to hospital discharge compared to SGA.