Abstract Body: Background: Prehospital advanced airway management may be associated with important complications, such as failed insertion attempts or the need to replace a successfully inserted airway. Only limited data describe the course and outcomes of these efforts.

Objective: Describe the reasons for abandoning or replacing advanced airway management devices in the Pragmatic Airway Resuscitation Trial (PART).

Methods: Secondary analysis of PART, a multicenter trial comparing airway management in adult out-of-hospital cardiac arrests (OHCA). Paramedics performed laryngeal tube (LT) and endotracheal intubation (ETI) per study protocol. For unsuccessful advanced airway management, paramedics reported the reasons for abandoning further airway insertion attempts. For successful advanced airway events, paramedics reported the reasons for removing the device. We further determined the reasons for the emergency department (ED) removal of successfully placed prehospital airway devices. We analyzed the data using descriptive techniques, including frequency (%).

Results: Of 3,004 patients, first airway techniques were LT 1,423, ETI 1,227, and BVM 354. First-effort success rates in advanced airways were LT 90.3% and ETI 51.6%. For the second effort, airway switches were LT to ETI [62 (45.0)] and ETI to LT [454 (76.4)]. Of 1,317 total ETI efforts, reasons for abandoning airway insertions were difficulty visualizing vocal cords [243 (18.5)], view obstructed by blood/vomit [(51 (3.9)], and difficult anatomy [50 (3.8)]. Of 1,928 total LT efforts, reasons for abandoning airway insertion were ventilation/device difficulties [39 (2.0)], uncertain placement [27 (1.4)], and obstruction by blood/vomit [20 (1.0)]. Reasons for removing successfully placed airways were ventilation/device difficulties [LT 37 (1.9); ETI 7 (0.5)], displacement [LT 19 (1.0); ETI 26 (2.0)], obstruction by blood/vomit [LT 20 (1.0); ETI 7 (0.5)], and uncertain placement [LT 17 (0.9); ETI 11 (0.8)]. Among 684 LTs transported to the ED, reasons for LT removal were unknown [416 (60.8)], physician discretion [194 (28.4)], and local protocol requirements [47 (6.9)].

Conclusion: Abandonment of airway insertion was more common with ETI, mainly due to poor vocal cord visualization. Successfully placed airways were replaced infrequently. EDs replaced a large portion of prehospital LTs. These data highlight the challenges of placing and maintaining advanced airway devices.