Do We Harm Patients by Intubating During In-Hospital Codes?
Patricia Kritek, MD
Intubation during arrest was associated with worse outcomes.
The 2015 American Heart Association Advanced Cardiovascular Life Support guidelines deemphasize advanced airway placement as a component of initial resuscitation. Out-of-hospital–arrest data suggest lower survival among patients who are intubated in the field (NEJM JW Emerg Med Feb 2013 and JAMA 2013; 309:257). To determine whether this applies to inpatients, investigators examined resuscitations of more than 108,000 patients in a U.S. registry.
Seventy percent of patients were intubated during their code events; most (95%) of these intubations occurred within 15 minutes of resuscitation. Patients with initial nonshockable rhythms (i.e., pulseless electrical activity [PEA] or asystole) were more likely to be intubated than were those with ventricular fibrillation or tachycardia (69% vs. 53%).
In a time-matched propensity analysis, patients who were intubated during resuscitation were significantly less likely to survive to discharge than those who were not (16% vs. 19%) and were less likely to be discharged with good functional status (11% vs. 14%). In subgroup analyses, associations between intubation and these outcomes were not seen in patients who had preexisting respiratory insufficiency but were more pronounced for patients with initial shockable rhythms.
This observational study raises important questions about an established practice: Attempts at intubation can interrupt chest compressions or slow defibrillation, potentially delaying these life-saving interventions, particularly for patients with ventricular fibrillation or tachycardia. However, the results still could be confounded by underlying differences between the intubated and nonintubated groups that weren’t captured by the statistical technique of propensity-matching. Therefore, I’m not ready to abandon efforts to intubate patients with in-house arrest, especially those with PEA or asystole. Moreover, when respiratory failure is the cause of an arrest, early advanced airway management is important as a potential remedy to the underlying pathophysiology.
Andersen LW et al. Association between tracheal intubation during adult in-hospital cardiac arrest and survival. JAMA 2017 Feb 7; 317:494. (http://dx.doi.org/10.1001/jama.2016.20165)
Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477. (http://dx.doi.org/10.1001/jama.2016.20626)
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