Nassal Michelle M J, Yang Betty Y, Hall Jane, Shin Jenny, Gage Christopher B, Powell Jonathan R, Panchal Ashish R, Latimer Andrew J, Wang Henry E, Rea Thomas D, Johnson Nicholas J
Department of Emergency Medicine, The Ohio State University, Columbus.
Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas.
JAMA Netw Open. 2025 Sep 2;8(9):e2532334. doi: 10.1001/jamanetworkopen.2025.32334.
Although advanced airway (AA) practice patterns have varied over time, their association with out-of-hospital cardiac arrest (OHCA) outcomes is unknown.
To determine the association between AA temporal practice patterns of emergency medical service (EMS) agencies and OHCA outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from multicenter EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival database. The study included adults (aged ≥18 years) with OHCA treated by EMS agencies that had 25 or more OHCA episodes annually from January 1, 2016, through December 31, 2022.
AA interventions included supraglottic airway (SGA) device use or endotracheal intubation (ETI). Patients were categorized into groups using the following EMS agency-level patterns defined by predominant AA use before and after 2019: (1) ongoing ETI, (2) ongoing SGA use (ongoing SGA), (3) transitioning from ETI to SGA use (ETI to SGA), or (4) transitioning from SGA use to ETI (SGA to ETI).
Mixed-effects logistic regression models accounting for EMS agency clustering and adjusting for Utstein variables were used to evaluate the association between EMS agency AA practice patterns and OHCA outcomes including return of spontaneous circulation (ROSC) and survival. Subanalyses were also conducted for agencies in the lowest survival quartile. Odds ratios (ORs) are reported with 95% CIs.
This study included 350 216 patients with OHCA treated by 254 eligible EMS agencies. The 214 EMS agencies (n = 305 341 patients) with a predominant AA pattern were grouped as follows for temporal pattern analysis: ongoing ETI (n = 72 [33.6%]), ongoing SGA (n = 66 [30.8%]), ETI to SGA (n = 67 [31.3%]), or SGA to ETI (n = 9 [4.2%]). Patients were predominantly male (62.2%), with a median age of 64 (IQR, 52-76) years, and most (81.7%) presented with nonshockable rhythms. ROSC occurred in 30.8% of patients, and 10.4% of patients survived to hospital discharge. Predominant SGA use among EMS agencies increased from 65 agencies in 2016 to 113 in 2022. ROSC decreased in all 4 groups from before to after 2019 as follows: from 36.5% to 30.7% (OR, 0.80 [95% CI, 0.77-0.82]) for ongoing ETI, from 32.4% to 26.4% (OR, 0.75 [95% CI, 0.73-0.78]) for ongoing SGA, from 32.1% to 28.5% (OR, 0.88 [95% CI, 0.85-0.91]) for ETI to SGA, and from 36.7% to 33.3% (OR, 0.92 [95% CI, 0.83-1.03]) for SGA to ETI. For the 15 lower-performing agencies (n = 20 860 patients) that transitioned from ETI to SGA after vs before 2019, an association with higher ROSC (from 25.7% to 29.1%; OR, 1.16 [95% CI, 1.09-1.24]) and survival (from 5.6% to 6.3%; OR, 1.17 [95% CI, 1.04-1.32]) was observed.
In this cohort study, SGA use among EMS agencies increased over time. Although ROSC declined for all AA temporal practice patterns, the transition from ETI to SGA use at EMS agencies with lower baseline survival was associated with improved outcomes. Future studies are warranted to confirm these findings and to evaluate whether the observed associations are consistent across diverse populations.
尽管高级气道（AA）的实践模式随时间有所变化，但其与院外心脏骤停（OHCA）结局的关联尚不清楚。
确定紧急医疗服务（EMS）机构的AA时间实践模式与OHCA结局之间的关联。
设计、设置和参与者：这项横断面研究使用了参与心脏骤停登记以提高生存率数据库的多中心EMS机构的数据。该研究纳入了2016年1月1日至2022年12月31日期间每年有25次或更多OHCA发作的EMS机构治疗的成年（≥18岁）OHCA患者。
AA干预措施包括使用声门上气道（SGA）装置或气管插管（ETI）。根据2019年前后主要的AA使用情况所定义的以下EMS机构层面模式，将患者分为几组：（1）持续进行ETI，（2）持续使用SGA（持续SGA），（3）从ETI过渡到使用SGA（ETI到SGA），或（4）从使用SGA过渡到ETI（SGA到ETI）。
使用考虑EMS机构聚类并对Utstein变量进行调整的混合效应逻辑回归模型，来评估EMS机构AA实践模式与OHCA结局（包括自主循环恢复（ROSC）和生存）之间的关联。还对生存最低四分位数的机构进行了亚组分析。报告的比值比（OR）及其95%置信区间（CI）。
本研究纳入了由254家符合条件的EMS机构治疗的350216例OHCA患者。将214家具有主要AA模式的EMS机构（n = 305341例患者）按以下方式分组进行时间模式分析：持续进行ETI（n = 72 [33.6%]），持续使用SGA（n = 66 [30.8%]），ETI到SGA（n = 67 [31.3%]），或SGA到ETI（n = 9 [4.2%]）。患者以男性为主（62.2%），中位年龄为64岁（四分位间距，52 - 76岁），且大多数（81.7%）表现为不可电击心律。30.8%的患者实现了ROSC，10.4%的患者存活至出院。EMS机构中主要使用SGA的情况从2016年的65家增加到2022年的113家。2019年前后，所有4组的ROSC均下降，情况如下：持续进行ETI组从36.5%降至30.7%（OR，0.80 [95% CI，0.77 - 0.82]），持续使用SGA组从32.4%降至26.4%（OR，0.75 [95% CI，0.73 - 0.78]），ETI到SGA组从32.1%降至28.5%（OR，0.88 [95% CI，0.85 - 0.91]），SGA到ETI组从36.7%降至33.3%（OR，0.92 [95% CI，0.83 - 1.03]）。对于2019年后与2019年前相比从ETI过渡到SGA的15家表现较差的机构（n = 20860例患者），观察到与更高的ROSC（从25.7%升至29.1%；OR，1.16 [95% CI，1.09 - 1.24]）和生存（从5.6%升至6.3%；OR，1.17 [95% CI，1.04 - 1.32]）相关。
在这项队列研究中,EMS机构中SGA的使用随时间增加。尽管所有AA时间实践模式的ROSC均下降，但基线生存率较低的EMS机构从ETI过渡到使用SGA与结局改善相关。未来有必要进行研究以证实这些发现，并评估观察到的关联在不同人群中是否一致。
