What is the preferred choice between Endotracheal Tube (ETT) and Supraglottic Airway (SGA) devices during Cardiopulmonary Resuscitation (CPR)?

ETI vs SGA in CPR

The choice between endotracheal intubation (ETI) and supraglottic airway (SGA) devices during CPR depends critically on your system's documented intubation success rates and provider experience—in settings with low ETI success rates (<70%), use SGA; in settings with high success rates (>90%), either device is acceptable. 1

Evidence-Based Decision Algorithm

For Out-of-Hospital Cardiac Arrest (OHCA)

In low-skill environments (ETI success <70%):

• Prefer SGA devices as they demonstrate superior outcomes when ETI success rates are suboptimal 1
• One large RCT (n=3004) showed laryngeal tube SGA improved survival to discharge (RR 1.34,95% CI 1.07-1.68) and neurologically favorable survival (RR 1.42,95% CI 1.07-1.89) compared to ETI in settings with 52% intubation success 1
• SGAs can be inserted without interrupting chest compressions, unlike ETI which requires direct visualization and compression pauses 2, 3

In high-skill environments (ETI success >90%):

• Either ETI or SGA is acceptable, as outcomes are equivalent 1
• One RCT (n=9296) comparing i-gel SGA with ETI found no difference in survival (RR 0.95) or neurological outcomes (RR 0.92) 1
• Another RCT (n=2043) with 98% ETI success showed no difference between ETI and bag-mask ventilation 1

For In-Hospital Cardiac Arrest

Expert providers can use either device (Class 2a recommendation) 1

• The critical factor is minimizing interruptions to chest compressions 2, 4
• One study showed SGAs reduced time to advanced airway placement from 8.6 minutes (ETI) to 4.7 minutes (SGA) during in-hospital arrests 5

Key Performance Considerations

Why Provider Skill Matters

• ETI requires frequent experience and retraining (Class 1 recommendation) 1
• Studies included in AHA guidelines showed ETI success rates ranging from 52% to 98%, demonstrating massive variability based on provider experience 1
• In the ROC PRIMED trial, successful ETI was associated with improved survival (adjusted OR 1.40) compared to SGA, but this reflects optimal performance conditions 6

Advantages of SGA Devices

• No interruption of chest compressions required for insertion 2, 3
• Easier initial training and skill maintenance compared to ETI 2, 3
• No direct visualization needed 3, 4
• Successful ventilation rates of 85-97% in cardiac arrest settings 3

Advantages of ETI (When Performed Successfully)

• Most secure airway with best aspiration protection 3, 4
• Better oxygenation and ventilation after prolonged CPR—one study showed median PaO2 of 71 mmHg (ETI) vs 58 mmHg (SGA) 7
• In patients receiving ECPR, ETI was associated with higher neurologically favorable survival (42% vs 29%) 7

Critical Pitfalls to Avoid

Prolonged intubation attempts:

• Limit laryngoscopy and tube passage to <10 seconds of compression interruption 4
• Have laryngoscope blade and tube fully prepared before pausing compressions 4

Unrecognized esophageal intubation:

• Mandatory waveform capnography for ETI confirmation (Class 1 recommendation) 2, 4
• Waveform capnography has 100% sensitivity and specificity for correct ETT placement 4
• Use colorimetric CO2 detectors or esophageal detector devices if waveform capnography unavailable 2, 3

Excessive ventilation:

• Once advanced airway placed, deliver continuous compressions at ≥100/minute 3
• Ventilate at 1 breath every 6-8 seconds (8-10 breaths/minute) 3
• Avoid excessive rates that compromise venous return 3

Quality Improvement Requirements

All EMS systems performing prehospital intubation must:

• Provide ongoing quality improvement programs (Class 1 recommendation) 1
• Track overall SGA and ETT placement success rates 1
• Monitor complications systematically 1

Special Circumstances

For witnessed shockable rhythms (VF/pulseless VT):

• Consider delaying ETI until after initial CPR and defibrillation attempts fail or ROSC achieved 4
• Bundles involving minimally interrupted cardiac resuscitation showed OR 3.6 for favorable neurologic outcome 4

For hypoxic arrest with copious vomitus:

• Qualified providers should consider rapid ETI for definitive airway protection 1

The bottom line: Choose the airway device that can be placed most quickly and reliably with minimal chest compression interruption, matching your documented system success rates 2, 4