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Randomized Controlled Trial
. 2025 Sep 2;8(9):e2531511.
doi: 10.1001/jamanetworkopen.2025.31511.

Advanced Airway Devices and End-Tidal Capnography Trends in Cardiac Arrest: A Secondary Analysis of a Randomized Clinical Trial

Michelle M J Nassal  1 , Andoni Elola  2 , Elisabete Aramendi  3 , Christopher B Gage  4 , Jonathan R Powell  5 , Xabier Jaureguibeitia  3 , Ahamed H Idris  6 , Mohamud R Daya  7 , Tom P Aufderheide  8 , Jestin Carlson  9 , Shannon W Stephens  10 , Graham Nichol  11 , Robert H Schmicker  12 , Ashish R Panchal  1   4 , Henry E Wang  1
Affiliations
Randomized Controlled Trial

Advanced Airway Devices and End-Tidal Capnography Trends in Cardiac Arrest: A Secondary Analysis of a Randomized Clinical Trial

Michelle M J Nassal et al. JAMA Netw Open. .

Abstract

Importance: While variable advanced airway devices are used in out-of-hospital cardiac arrest (OHCA) resuscitation, potential differences in ventilation metrics are not well known.

Objective: To characterize differences in end-tidal carbon dioxide (EtCO2) capnography trajectories between laryngeal tube (LT) and endotracheal intubation (ETI) during OHCA.

Design, setting, and participants: This secondary analysis of EtCO2 capnography waveforms from the Pragmatic Airway Resuscitation Trial (PART), a multicenter cluster-crossover randomized clinical trial, was performed November 1, 2023, through July 8, 2025. Participants in this analysis were adults (aged ≥18 years) with nontraumatic OHCA from 27 emergency medical services (EMS) agencies, which were placed into 13 clusters. Participants were assigned to LT or ETI airway management. All cases with 50% or greater interpretable EtCO2 signal were included.

Interventions: LT vs ETI airway management.

Main outcomes and measures: Mean maximal EtCO2 values within 1-minute epochs and trends over resuscitation after LT or ETI. Associations with OHCA outcomes were also evaluated, including sustained return of spontaneous circulation (ROSC) and 72-hour survival. Using the Mann-Whitney test, EtCO2 of LT and ETI cases were compared at 20-, 10-, and 1-minute resuscitation. EtCO2 trends over time were evaluated using Cochran-Armitage test of trend. Covariates in multivariable logistic regression models for outcomes were adjusted, including interaction between advanced airway device and EtCO2 trends.

Results: Of the 3004 cases in PART, 1113 (818 in LT and 295 in ETI groups) had available EtCO2 data and were included in the secondary analysis. Patients were mostly male (694 [62.4%]), had a median (IQR) age of 64 (52-75) years, and had a nonshockable (941 [84.6%]), nonpublic (999 [89.8%]) OHCA. ROSC occurred in 144 patients (17.6%) receiving LT and 54 (18.3%) receiving ETI. EtCO2 values did not differ between LT and ETI groups (20-minute resuscitation: 33.9 vs 29.4 mm Hg, P = .07; 10-minute resuscitation: 30.9 vs 28.5 mm Hg, P = .89; 1-minute resuscitation: 32.2 vs 28.3 mm Hg, P = .28). In ROSC compared with non-ROSC cases, patients in LT (27.9 to 52.3 mm Hg vs 32.6 to 23.5 mm Hg; P < .001) and ETI (38.2 to 46.7 mm Hg vs 27.7 to 20.0 mm Hg; P < .001) groups exhibited increasing EtCO2 during resuscitation. EtCO2 trend and advanced airway interaction was associated with ROSC (odds ratio [OR], 1.75; 95% CI, 1.25-2.45) but not survival (OR, 1.21; 95% CI, 0.90-1.61). Therefore, we performed an advanced airway stratified analysis for ROSC (ETI: OR, 2.34 [95% CI, 1.67-3.26]; LT: OR, 1.33 [95% CI, 1.20-1.47]).

Conclusions and relevance: In this secondary analysis of PART, EtCO2 values did not differ between LT and ETI. However, due to significant interaction between advanced airway device and EtCO2 trends, individual interpretation of these parameters may not be accurate.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nassal reported receiving grants from the National Heart Lung and Blood Institute (NHLBI) during the conduct of the study. Dr Aramendi reported receiving grants from the Basque Government, Ministerio de Ciencia, Innovación y Universidades, and The Ohio State University during the conduct of the study. Dr Jaureguibeitia reported receiving grants from the Spanish Ministry of Science, Innovation and Universities and the Basque Government during the conduct of the study. Dr Idris reported receiving grants from the University of Texas Southwestern during the conduct of the study outside the submitted work; being an unpaid volunteer for the American Heart Association Emergency Cardiovascular Care Committee; and serving on the Stryker clinical advisory board. Dr Daya reported receiving grants from the National Institute of Health during the conduct of the study. Dr Aufderheide reported receiving grants from the NHLBI, the National Institute of Neurological Disorders and Stroke, the National Center for Advancing Translational Sciences, ZOLL, Inflammatix, Cytovale, Abbott, MeMed, and AstraZeneca; nonfinancial support from ZOLL and Moberg; and personal fees from Medtronic during the conduct of the study. Mr Stephens reported receiving grants from the NHLBI during the conduct of the study and grants from CSL Behring, CeleCor Therapeutics, Infrascan, and Arsenal Medical outside the submitted work. Dr Nichol reported receiving salary support from Medic One Foundation via the endowed research chair at University of Washington; grants from the Patient Centered Outcomes Research Institute; research contracts from Johnson & Johnson, Heart Recovery, ZOLL, Magenta Medical, and RCE Technologies; a research contract and personal fees from CeleCor Therapeutics; and personal fees from Orixha outside the submitted work; and holding an issued patent (Measurement of blood flow during CPR) assigned to University of Washington and a pending patent (Non-provisional patent for measurement reperfusion-injury modifying device) assigned to University of Washington outside the submitted work. Mr Schmicker reported receiving grants from the University of Washington during the conduct of the study. Dr Wang reported receiving grants from the NHLBI during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cases Included in the Analysis
Analysis limited to 1172 patients in the Pragmatic Airway Resuscitation Trial (PART) with end-tidal carbon dioxide (EtCO2) capnography recordings. CPR indicates cardiopulmonary resuscitation; ETI, endotracheal intubation; LT, laryngeal tube; and ROSC, return of spontaneous circulation.
Figure 2.
Figure 2.. End-Tidal Carbon Dioxide (EtCO2) Capnography vs Time
ETI indicates endotracheal intubation; LT, laryngeal tube.
Figure 3.
Figure 3.. End-Tidal Carbon Dioxide (EtCO2) Capnography vs Time, Stratified by Advanced Airway Technique
Box plots describe EtCO2 capnography values in 1-minute epochs. Vertical dashed line indicates end of resuscitation. ETI indicates endotracheal intubation; LT, laryngeal tube; and ROSC, return of spontaneous circulation.
See this image and copyright information in PMC

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