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Should Adults Experiencing In-Hospital Cardiac Arrest Be Intubated?

Sofer, Dalia

AJN The American Journal of Nursing: May 2017 - Volume 117 - Issue 5 - p 12
doi: 10.1097/01.NAJ.0000516256.25355.e7
In the News

A new study challenges conventional wisdom.

Dalia Sofer

It is common practice to intubate adults who experience in-hospital cardiac arrest, though the effectiveness of this intervention is largely unknown. Now comes evidence from a large, observational study that survival to discharge was actually lower among patients who underwent early tracheal intubation compared with patients treated by cardiopulmonary resuscitation alone.

Researchers analyzed data for 108,079 adult patients at 668 hospitals from January 2000 to December 2014, using the Get with the Guidelines–Resuscitation registry, a U.S.-based registry of adult patients who experienced cardiac arrest while in the hospital. The study focused on the 71,615 (66.3%) patients who were intubated within the first 15 minutes of arresting. Median age was 70 years, and 41% were female.

The researchers compared a portion of this cohort (43,314 patients or 60.5%) to control patients who were not intubated and found that the intubated patients were less likely to survive than the resuscitation-only patients (16.3% versus 19.4%, respectively). Intubated patients were also less likely to experience a return of spontaneous circulation, defined as no further need for chest compressions sustained for at least 20 minutes, and had a lower rate of good functional outcome—defined as either mild or no neurological deficit, or only moderate cerebral disability. In addition, intubated patients with an initial shockable rhythm (pulseless ventricular tachycardia or ventricular fibrillation) were much less likely to survive than intubated patients with an initial nonshockable rhythm (asystole or pulseless electrical activity)—a 32% relative decrease for the former group compared with a 9% relative decrease for the latter.

Because their analysis was limited to data available through the registry, the researchers were unable to eliminate potential confounders such as the “skills and experience of health care professionals, the underlying cause of the cardiac arrest, the quality of chest compressions, and the indication for intubation.” Still, they concluded that the study results do not support early intubation for hospitalized adults who experience cardiac arrest. Given the popularity of this practice, the researchers called for additional randomized clinical trials of sufficient size to yield useful results.

Mary M. Brennan, program director of the adult–gerontology acute care NP program at New York University's Rory Meyers College of Nursing, agrees that clinical trials are needed to better understand the influence of confounding factors. “Patients who were not intubated had a statistically significant shorter time to the return of spontaneous circulation,” she told AJN. “Could these patients have represented a healthier cohort of patients who were more responsive to the initial resuscitation attempts?”

Derek C. Angus, chair of the Department of Critical Care Medicine at the University of Pittsburgh, also would like further study, though he points out the difficulty of designing a clinical trial capable of delineating confounders’ impact. Still, he writes in an accompanying editorial, the observational study's results show that “clear demonstration of benefit is lacking” for intubation. “This is hardly a ringing endorsement for such an established intervention that requires substantial cost to provide, considering both the training and staffing costs… of mechanical ventilation and intensive care that are incurred once the patient is intubated.” —Dalia Sofer

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REFERENCE

Andersen LW, et al for the American Heart Association's Get with the Guidelines–Resuscitation Investigators. JAMA 2017;317(5):494-506; Angus DC. JAMA 2017;317(5):477-8.
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