Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes.

Importance: Although advanced airway (AA) practice patterns have varied over time, their association with out-of-hospital cardiac arrest (OHCA) outcomes is unknown. Objective: 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. Exposure: 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). Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.