Bayesian Analysis of the Pragmatic Airway Resuscitation Trial - 25/11/19
, Andrew Humbert, MS c, Graham Nichol, MD d, Jestin N. Carlson, MD, MS e, f, Mohamud R. Daya, MD, MS g, Ryan P. Radecki, MD h, Matthew Hansen, MD, MCR g, Clifton W. Callaway, MD, PhD e, Claudia Pedroza, PhD bAbstract |
Study objective |
Intubation and laryngeal tube insertion are common airway management strategies in out-of-hospital cardiac arrest. Bayesian analysis offers an alternate statistical approach to assess the results of a trial. We use Bayesian analysis to compare the effectiveness of initial laryngeal tube versus initial intubation strategies on outcomes after out-of-hospital cardiac arrest in the Pragmatic Airway Resuscitation Trial.
Methods |
We performed a post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial. We defined prior distributions representing neutral or skeptical estimates of laryngeal tube benefit. Using Bayesian log binomial models, we fit models for 72-hour survival, hospital survival, and hospital survival with favorable neurologic status. We estimated the posterior probability (the probability of observing an effect difference between treatment groups) of the benefit of laryngeal tube over intubation on out-of-hospital cardiac arrest outcomes.
Results |
The parent trial enrolled 3,004 patients (1,505 laryngeal tube, 1,499 intubation). Under a neutral prior distribution (relative risk 1.0), laryngeal tube was better than intubation (72-hour survival risk difference 1.8% [95% credible interval {CrI} –0.9% to 4.5%], posterior probability 91%; hospital survival 1.4% [95% CrI –0.4% to 3.4%], posterior probability 93%; and hospital survival with favorable neurologic status 0.7% [95% CrI –0.5% to 2.1%], posterior probability 86%). Under a skeptical prior distribution (relative risk 0.83 to 0.92), laryngeal tube was also better than intubation (72-hour survival risk difference 1.7% [95% CrI –0.9% to 4.3%], posterior probability 89%; hospital survival 1.3% [95% CrI –0.5% to 3.3%], posterior probability 91%; and hospital survival with favorable neurologic status 0.6% [95% CrI –0.5% to 2.0%], posterior probability 82%).
Conclusion |
Under various prior assumptions, post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial confirmed better out-of-hospital cardiac arrest outcomes with a strategy of initial laryngeal tube than initial intubation.
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| Please see page 810 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors. Dr. Green was the supervising editor on this article. Dr. Wang did not participate in the editorial review or decision to publish this article. |
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| Author contributions: HEW and CP were responsible for design and conceptualization of the study. HEW and GN obtained funding. All authors were responsible for execution of the study, data collection, and critical review and approval of the article. AH and CP were responsible for data analysis. HEW, AH, and CP were responsible for composition of the article. HEW takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Supported by award UH2/UH3-HL125163 from the National Heart, Lung, and Blood Institute (NHLBI). The Resuscitation Outcomes Consortium institutions participating in the trial were supported by a series of cooperative agreements from the NHLBI, including 5U01 HL077863 (University of Washington Data Coordinating Center), HL077866 (Medical College of Wisconsin), HL077871 (University of Pittsburgh), HL077873 (Oregon Health & Science University), HL077881 (University of Alabama at Birmingham), and HL077887 (University of Texas Southwestern Medical Center/Dallas). Ambu, Inc. provided laryngeal tube airways to replace equipment used by EMS agencies during the trial. Dr. Nichol receives salary support from the University of Washington through the Leonard A. Cobb Medic One Foundation Endowed Chair in Prehospital Emergency Care. The Medic One Foundation raises funds to promote improvements in out-of-hospital emergency care. He receives support from ZOLL Medical Corp, which manufactures portable ventilators. He is a consultant to GE Healthcare, which manufactures portable ventilators. His activities with ZOLL Medical and GE Healthcare are unrelated to ventilators. He is a consultant to ZOLL Circulation Inc, a subsidiary of ZOLL Medical Corp. He has been assigned a provisional patent for a combination product to modify reperfusion injury to the University of Washington. Dr. Carlson receives support from the American Heart Association for intubation research. |
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| Trial registration number: NCT02419573 |
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| The NHLBI had the following roles in the study: design and conduct of the study; review, advising, and approval of study design; participation in monitoring enrollment progress; and assembly of the data and safety and monitoring board. Ambu, Inc. did have not any role in the design, execution, or analysis of the trial. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NHLBI or the National Institutes of Health. |
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Vol 74 - N° 6
P. 809-817 - décembre 2019 Retour au numéro
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