We thank Mr. Wood and Mr. Podsialdo for their insightful comments regarding the Pragmatic Airway Resuscitation Trial (PART) results

With regards to their comment of prior studies finding better outcomes with intubation than supraglottic airways, one must bear in mind that these prior studies were biased by their retrospective designs; the airway was selected by paramedic choice and may have been influenced by a range of factors such as the patient’s condition, anatomy, the physical environment or the practitioner’s level of comfort. Meta-analysis or systematic reviews of these retrospective studies also unfortunately suffer from these same limitations primarily related to confounding by indication.1 Randomization is the only way to overcome these biases.

PART is one of the first prospective randomized studies to compare airway strategies in adults with out-of-hospital cardiac arrest. Therefore, it’s not surprising that a randomized study such as PART found a result completely opposite to prior studies based upon retrospective observational data. History has many examples of ineffective EMS interventions being disproven by randomized trials; examples include the use of MAST trousers in trauma, early fluid resuscitation in penetrating torso trauma and prehospital induction of mild hypothermia in out-of-hospital cardiac arrest (OHCA).2–4

The 3% difference in survival seen in the PART study is a very important finding when you consider that OHCA affects nearly 350,000 individuals and survival in the United States remains less than 10%. Based upon these estimates, thousands of extra lives could be saved each year from initial King LT use in OHCA.

We too are concerned by the 51.3% intubation success rate. However, the vast majority of these cases were successfully rescued by LT insertion. EMS personnel in participating agencies were likely carrying out sensible airway management strategies promoted by their medical directors: If you’re having trouble intubating, move quickly to rescue laryngeal tube insertion. It’s hard to argue with this practical approach.

Raising the EMS intubation bar in the U.S. is a noble goal, but an unrealistic challenge, as many communities can’t even assure live intubation experience for paramedic students. The development of non-invasive ventilation options has also further reduced the need to intubate patients in emergency settings, further limiting field airway experience.

Finally, contrary to what Mr. Woods and Mr. Podsialdo suggest, PART is not an illustration of the evils of intubation. Rather, PART shines a spotlight on the challenges of using an “intubation-first” strategy in the incredibly difficult out-of-hospital setting for critically ill cardiac arrest patients. We hope that these findings open the door to novel airway management strategies in all healthcare settings.

References

1. Kyriacou DN, Lewis RJ. Confounding by indication in clinical research. JAMA. 2016;316(17):1818–1819.

2. Mattox KL, Bickell W, Pepe PE, et al. Prospective MAST study in 911 patients. J Trauma. 1989;29(8):1104–1111.

3. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105–1109.

4. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: A randomized clinical trial. JAMA. 2014;311(1):45–52.

Read the original letter to the authors

It’s About Paramedic Intubation Skill Maintenance, Not ETI vs. SGA
Letter to JEMS: What does the PART study really tell us? It’s not what you think!
By Stephen P. Wood, MS, ACNP-BC , Benjamin Podsiadlo, EMT-P