What is the preferred choice between Endotracheal Intubation (ETI) and Supraglottic Airway (SGA) devices for airway management in a prehospital setting?

Prehospital Airway Management: ETI vs SGA

Direct Recommendation

In the prehospital setting, supraglottic airway (SGA) devices should be the preferred initial advanced airway for most providers, particularly when endotracheal intubation (ETI) success rates are below 90%. 1

Evidence-Based Decision Algorithm

When to Choose SGA as Primary Device

• Use SGA when ETI success rates are <70%: In low-skill environments, SGAs 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. 1

• SGA demonstrates superior first-pass success: Real-world prehospital data shows 96% first-pass success with SGA versus 68% with ETI, with inability to visualize the airway cited in 52% of failed ETI attempts. 2

• Faster airway placement: SGA achieves successful placement in 5.9 minutes versus 8.3 minutes for ETI first-pass, and 6.0 minutes versus 9.6 minutes for overall successful placement. 2

• Fewer attempts required: Multiple placement attempts were needed in 26% of ETI cases versus only 1% of SGA cases. 2

When ETI and SGA Are Equivalent

• High-skill environments (ETI success >90%): Either device is acceptable when providers demonstrate consistently high intubation success rates, as outcomes are equivalent (survival RR 0.95, neurological outcomes RR 0.92). 1

• No difference in primary outcomes: Large systematic reviews found no differences in mortality, neurological function, or ROSC between BVM, SGA, and ETI across cardiac arrest, trauma, and medical emergencies. 3

• Similar complication rates: No statistically significant differences in complications between ETI and SGA cohorts in prehospital settings. 2

Key Advantages of SGA in Prehospital Setting

• No visualization required: SGAs do not require direct visualization of the glottis, making initial training and skill maintenance easier. 4, 1

• No interruption of chest compressions: Can be inserted without interrupting CPR during cardiac arrest. 4, 1

• Reasonable alternative to ETI: American Heart Association classifies SGAs as Class IIa, LOE A alternative to ETI for healthcare professionals trained in their use. 1

Critical Requirements for ETI Use

• Mandatory quality improvement: All EMS systems performing prehospital intubation must provide ongoing quality improvement programs, track overall success rates, and monitor complications systematically (Class 1 recommendation). 1

• Frequent experience required: ETI requires frequent experience and retraining (Class 1 recommendation), with successful ETI associated with improved survival (adjusted OR 1.40) only in optimal performance conditions. 1

• Waveform capnography mandatory: Confirmation of correct ETI placement requires waveform capnography (Class I, LOE A) in addition to clinical assessment. 1

Special Considerations for Trauma

• Oxygenation takes absolute priority: In trauma patients, oxygenation takes priority over definitively securing the airway unless airway control is required to achieve oxygenation. 5

• Manual in-line stabilization: Apply manual in-line stabilization during intubation rather than relying solely on cervical collar immobilization when cervical spine injury is suspected. 4, 5

• Videolaryngoscopy preferred: Use videolaryngoscopy as first-line technique if available and operator is experienced. 5

Common Pitfalls to Avoid

• Multiple ETI attempts: Do not attempt multiple intubation attempts in the setting of rapid refractory hypoxemia; transition to SGA or front-of-neck access. 6

• Excessive ventilation: Avoid excessive ventilation rates as this compromises venous return and cardiac output; deliver 1 breath every 6-8 seconds (8-10 breaths/minute) once advanced airway is placed. 1

• Delayed recognition of failure: Do not wait for life-threatening hypoxemia before transitioning to alternative airway strategies. 4

Post-Placement Management

• Continuous chest compressions: Once advanced airway is in place during cardiac arrest, deliver continuous chest compressions at rate of at least 100 per minute without pauses for ventilation. 1

• Appropriate tidal volumes: Maintain tidal volumes of 6-7 mL/kg to avoid excessive ventilation and gastric insufflation. 5

• Confirmation required: Use waveform capnography for all intubations to verify tube placement and monitor ventilation adequacy. 5