Paramedics commonly perform endotracheal intubation on patients who have out-of-hospital cardiac arrest, but there is little evidence comparing this approach with other airway management techniques. A multicenter cluster-crossover randomized trial compared the effectiveness of initial laryngeal tube insertion with initial endotracheal intubation in adults who had an out-of-hospital cardiac arrest.

The 27 emergency medical service agencies participating in the study were randomized into clusters and then to one of two initial advanced airway management strategies: laryngeal tube insertion or endotracheal intubation. Each cluster crossed over to the other airway management strategy at three to five months. A total of 3,004 adults with nontraumatic out-of-hospital cardiac arrest and an anticipated need for ventilator support or advanced airway management were included in the study.

Significantly more patients with laryngeal tube insertion than endotracheal intubation survived for 72 hours, the primary outcome (18.3% versus 15.4%). Secondary outcomes were also better in patients who had a laryngeal tube inserted compared with endotracheal intubation (return of spontaneous circulation, 27.9% versus 24.3%; hospital survival, 10.8% versus 8.1%; and favorable neurologic status at discharge, 7.1% versus 5%). There were no significant differences in terms of oropharyngeal or hypopharyngeal injury, airway swelling, or pneumonia or pneumonitis among those who had laryngeal tube insertion compared with those who had endotracheal intubation.

The authors point out that the study has several limitations. No additional training in laryngeal tube insertion or endotracheal intubation was provided, and there was no monitoring of technique nor assessment of chest compression effectiveness or the quality of ventilation. Also, key elements of the trial were not blinded. It's also important to note that the success rate of endotracheal intubation in this study was considerably lower than that shown in a 2010 meta-analysis by Hubble and colleagues in Prehospital Emergency Care. The authors conclude that laryngeal tube insertion may be considered as an initial airway management strategy for adults with out-of-hospital cardiac arrest.

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