Worldwide, death from cardiac arrest in the out-of-hospital setting remains the leading cause of mortality. Focuses have aimed at improving bystander CPR, public access to AEDs, minimizing chest compression interruptions, and decreasing the emphasis on advanced airway management. This latter concept has become so important that the AHA/ASA have now changed their “ABC” philosophy to “CAB.” Below is the review of the literature that has changed this philosophy.

Does Prehospital Intubation Attempts Affect Survival to Hospital Discharge in Out-of-Hospital Cardiac Arrest (OHCA)? 1

What they did

  • Retrospective study design at single site (Mecklenbeurg County, NC)
  • 1,142 cardiac arrests

Primary outcomes

  • Pre-hospital return of spontaneous circulation (ROSC)
  • Survival to hospital discharge

Descriptive data

  • 697/1142 (61%) of patients were male
  • 619/1142 (54.2%) of patients were Caucasian
  • 302/1142 (25.5%) had VF/VT arrest
  • 142/1142 (12.8%) witnessed by EMS or first responders
  • 299/1142 (26.2%) had pre-hospital ROSC


  • Pre-hospital endotracheal intubation (ETI) vs NO ETI: 25.3% vs 45.3% with pre-hospital ROSC
  • 118/299 (39.5%) of patients with ROSC were discharged alive


  • ETI attempts was a self reported variable
  • Some outcome data from the hospitals was missing


There is a NEGATIVE association between pre-hospital ETI attempts and survival from OHCA.

Does Prehospital Intubation Attempts Affect Survival and Neurologic Outcome in Out-of-Hospital Cardiac Arrest (OHCA)? 2

What they did

  • Prospective, nationwide, population-based study using all-Japan Utstein Registry
  • 649,654 adults in Japan with OHCA

Primary outcome

  • Favorable neurological outcome 1 month after OHCA

Descriptive data

  • 367,837/649,359 (57%) underwent BVM
  • 281,522/649,359 (43%) underwent advanced airway management
  • Overall rate of ROSC 6.5%
  • Overall rate of 1 month survival 4.7%
  • Overall rate of favorable neurologic outcome 2.2%


Looking at ETI vs supraglottic airway vs BVM 

  • Favorable neurological outcome: 1.0%, 1.1%, and 2.9%, respectively
  • OR for favorable neurological outcome: 0.41, 0.38, 0.38, respectively


  • Observational study
  • Absence of information regarding the process of intubation
  • Japanese population only


In OHCA, advanced airway (ETI or supraglottic airway) was independently associated with a DECREASED neurologically favorable outcome compared to conventional BVM.

Bottom Line

Pre-hospital advanced airway WORSENS survival and neurologic outcome in OHCA.

Hasegawa K, Hiraide A, Chang Y, Brown D. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA. 2013;309(3):257-266. [PubMed]
Studnek J, Thestrup L, Vandeventer S, et al. The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med. 2010;17(9):918-925. [PubMed]
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor Clinical Assistant Professor of EM and IM University of Texas Health Science Center at San Antonio Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews