What is the recommended approach to airway management in the Airway 2 trial?

Airway Management in the AIRWAYS-2 Trial

In the AIRWAYS-2 trial, the recommended approach to airway management is to use either bag-mask ventilation (BMV) or an advanced airway strategy (specifically comparing i-gel supraglottic airway device versus tracheal intubation) during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. 1

Trial Design and Comparison

The AIRWAYS-2 trial was a large-scale cluster randomized controlled trial conducted in the English emergency medical services that compared two airway management strategies:

• i-gel supraglottic airway device: A second-generation supraglottic airway used as the initial advanced airway intervention 2
• Tracheal intubation: Traditional endotracheal intubation technique 2

The trial used a cluster-crossover randomized design where individual paramedics were the unit of randomization, with automatic enrollment of all eligible patients to avoid selection bias 3, 2.

Key Findings and Recommendations

Primary Approach

• The trial found no high-certainty evidence to recommend an advanced airway strategy over bag-mask ventilation (BMV) during CPR for adult cardiac arrest 1
• Similarly, there was no high-certainty evidence to recommend a specific advanced airway device over another 1

Implementation Considerations

• The trial enrolled adults with non-traumatic out-of-hospital cardiac arrest attended by participating paramedics 2
• The primary outcome measured was the modified Rankin Scale score at hospital discharge, focusing on functional neurological outcomes 2
• Secondary outcomes included measures related to airway management success, hospital stay, and recovery at 3 and 6 months 2

Clinical Application

When managing airways in cardiac arrest situations similar to those in the AIRWAYS-2 trial:

• Call for help early when difficulties are encountered 1
• Optimize oxygenation throughout the airway management process 1
• Limit the number of attempts at tracheal intubation or supraglottic airway placement to avoid potential injury and complications 1
• Be aware of the passage of time, number of attempts, and oxygen saturation during the resuscitation effort 1
• Test mask ventilation after each attempt when feasible 1

Advanced Airway Management Considerations

If an advanced airway approach is selected:

• Identify a preferred sequence of devices to use for airway management 1
• Consider combination techniques if difficulty is encountered with individual techniques 1
• Have backup plans ready for both noninvasive and invasive approaches 1
• Use algorithms and cognitive aids when appropriate to guide decision-making 1

Common Pitfalls to Avoid

• Persistent attempts at direct laryngoscopy without changing approach can lead to preventable harm and delay in employing alternative strategies 1
• Failure to recognize when to transition from one airway technique to another can lead to complications 1
• Inadequate preparation for difficult airway scenarios increases risk of adverse outcomes 4
• Lack of team communication during airway emergencies can compromise patient safety 1

The AIRWAYS-2 trial provides important evidence regarding airway management strategies during out-of-hospital cardiac arrest, but does not definitively establish superiority of any single approach, suggesting that both BMV and advanced airway techniques remain reasonable options depending on provider skill and clinical circumstances 1, 2.