INTRODUCTION: Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. The primary aim of this study was to describe pre-hospital airway management in adult patients post-OHCA. Secondary aims were to investigate whether tracheal intubation (TI) versus use of supraglottic airway device (SGA) was associated with patients' outcomes, including ventilator-free days within 26 days of randomization, 6 months neurological outcome and mortality. METHODS: Secondary analysis of the Target Temperature Management-2 (TTM2) trial conducted in 13 countries, including adult patients with OHCA and return of spontaneous circulation, with data available on pre-hospital airway management. A multivariate logistic regression model with backward stepwise selection was employed to assess whether TI versus SGA was associated with outcomes. RESULTS: Of the 1900 TTM2 trial patients, 1702 patients (89.5%) were included, with a mean age of 64 years (Standard Deviation, SD = 13.53); 79.1% were males. Pre-hospital airway management was SGA in 484 (28.4%), and TI in 1218 (71.6%) patients. At hospital admission, 87.8% of patients with SGA and 98.5% with TI were mechanically ventilated (p < 0.001). In the multivariate analysis, TI in comparison with SGA was not independently associated with an increase in ventilator-free days within 26 days of randomization, improved neurological outcomes, or decreased mortality. The hazard ratio for mortality with TI vs. SGA was 1.06, 95%Confidence Interval (CI) 0.88-1.28, p = 0.54. CONCLUSIONS: In the multicentre randomized TTM2-trial including patients with OHCA, most patients received prehospital endotracheal intubation to manage their airway. The choice of pre-hospital airway device was not independently associated with patient clinical outcomes. TRIAL REGISTRATION NUMBER: NCT02908308.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University Prague and General University Hospital Prague U Nemocnice 2 128 00 Prague 2 Czech Republic

Adult Critical Care University Hospital of Wales Cardiff UK

Anesthesia and Intensive Care IRCCS Ospedale Policlinico San Martino Genova Italy; Department of Surgical Science and Integrated Diagnostics University of Genoa Genova Italy

Australian and New Zealand Intensive Care Research Centre Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia; University College Dublin Clinical Research Centre at St Vincent's University Hospital Dublin Ireland

Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Australia; Department of Intensive Care Austin Hospital Heidelberg Australia

Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark; Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark

Critical Care Division and Department of Intensive Care Medicine The George Institute for Global Health and St George Hospital Clinical School University of New South Wales Sydney Australia

Department of Anaesthesia and Intensive Care Biomedical and Clinical Sciences Linköping University Linköping Sweden

Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg 423 45 Gothenburg Sweden

Department of Clinical Medicine Anaesthesiology and Intensive Care Lund University Lund Sweden

Department of Clinical Science and Education Södersjukhuset Center for Resuscitation Science Karolinska Institutet Stockholm Sweden

Department of Clinical Sciences Lund Anaesthesia and Intensive Care and Clinical Sciences Helsingborg Helsingborg Hospital Lund University Lund Sweden

Department of Clinical Sciences Lund Anesthesia and Intensive Care Lund University Lund Sweden

Department of Clinical Sciences Lund Cardiology Skåne University Hospital Lund University Lund Sweden

Department of Clinical Sciences Lund Neurology Skåne University Hospital Lund University Getingevägen 4 222 41 Lund Sweden

Department of Clinical Sciences Malmö Lund University Malmö Sweden; Department of Operation and Intensive Care Lund University Hallands Hospital Halmstad Halland Sweden

Department of Health Sciences University of Genoa Genova Italy

Department of Intensive Care Medicine Aarhus University Hospital Denmark Department of Clinical Medicine Aarhus University Denmark

Department of Intensive Care Medicine Inselspital Bern University Hospital University of Bern Bern Switzerland

Department of Intensive Care Medicine Université Libre de Bruxelles Hopital Universitaire de Bruxelles Brussels Belgium

Department of Internal Medicine Faculty of Medicine in Hradec Králové Charles University Hradec Králové Czech Republic; Department of Internal Medicine Cardioangiology University Hospital Hradec Králové Hradec Králové Czech Republic

Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria

Institute of Intensive Care Medicine University Hospital Zurich Rämistrasse 100 8091 Zurich Switzerland

Malcolm Fisher Department of Intensive Care Royal North Shore Hospital Critical Care Division The George Institute for Global Health Faculty of Medicine UNSW Sydney Sydney Australia

Medical Research Institute of New Zealand Private Bag 7902 Wellington 6242 New Zealand; Intensive Care Unit Wellington Regional Hospital Wellington New Zealand; Australian and New Zealand Intensive Care Research Centre Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia; Department of Critical Care University of Melbourne Parkville VIC Australia

University Hospitals Bristol NHS Foundation Trust Bristol UK

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NCT02908308