Airway Management in Out-of-Hospital Emergencies

Key Messages

What Is the Issue?

• Airway management is key to prehospital emergency care, impacting a patient’s survival and recovery. Endotracheal intubation has been considered the gold standard for airway management, yet its success in uncontrolled settings such as outside of the hospital can vary owing to the complexity of the procedure.
• Extraglottic airway devices, which include supraglottic and retroglottic airway devices, are an easier-to-insert alternative to endotracheal intubation; however, their impact on patient outcomes needs review.

What Did We Do?

• We compared the effectiveness of different types of extraglottic airway devices with endotracheal intubation, to inform decisions regarding the use of extraglottic airway devices in out-of-hospital emergencies. We focused on 2 types of supraglottic airway devices (i-gels and laryngeal mask airways) and 1 type of retroglottic airway device (King laryngeal tubes). We also sought to identify evidence-based guidelines regarding the use of extraglottic airway devices for this patient population.
• We searched key resources, including journal citation databases and conducted a focused internet search for relevant evidence published since 2019. Identified literature was reviewed, appraised, and summarized.

What Did We Find?

• Most identified studies were largely comprised of adults who had an out-of-hospital cardiac arrest (OHCA).
• I-gels were associated with higher rates of successful device insertion compared with King laryngeal tubes and laryngeal mask airways. I-gels also had higher rates of survival and return of spontaneous circulation (ROSC), and similar rates of adverse events compared with King laryngeal tubes. Significant differences for first-pass success, survival, and ROSC between i-gels and laryngeal mask airways were not reported. We did not identify any studies that met the inclusion criteria for this review that compared laryngeal mask airways with King laryngeal tubes.
• When compared with endotracheal intubation, i-gels and King laryngeal tubes were associated with higher rates of successful device insertion; however, King laryngeal tubes, laryngeal mask airways, and i-gels tended to have similar clinical outcomes or inconsistent findings. Exceptions included King laryngeal tubes having higher rates of ROSC, and laryngeal mask airways having lower survival to admission, though the difference on survival to discharge was not significant. A subgroup analysis by a randomized controlled trial (RCT) suggested i-gels may lead to better outcomes than endotracheal intubation for specific patients.
• In a nonrandomized study (NRS) that included patients with noncardiac arrest emergencies as well as pediatric patients, extraglottic airway devices were associated with higher rates of first-pass success than endotracheal intubation, with a larger effect seen in pediatric patients.
• One evidence-based guideline suggested supraglottic airway devices may be used for patients who had an OHCA. For pediatric patients who had an OHCA, experienced trauma, or experienced a medical emergency, the guideline recommended supraglottic airway devices compared with endotracheal intubation. The guideline noted missing sufficient evidence to make strong recommendations, yet reported that:
• o      supraglottic airway devices were favoured compared with endotracheal intubation for pediatric patients owing to factors such as higher first-pass success rates, harms associated with failed endotracheal intubation attempts, and procedure rarity.
• o      for adults who had an OHCA or medical emergency and determining between supraglottic airway devices and endotracheal intubation, the authors recommended considering documented success with endotracheal intubation. The authors recommended supraglottic airway devices for systems without documented success, and for systems with documented success, they suggested using either strategy.

What Does it Mean?

• Additional high-quality randomized studies are needed to fully understand the impact of extraglottic airway devices on patient-important outcomes for OHCA as well as other indications and for pediatric patients.
• Studies reported that i-gels were easier to insert and may also be associated with improved outcomes compared with King laryngeal tubes and similar outcomes compared with laryngeal mask airways. The use of the extraglottic airway devices was reported to result in similar patient outcomes as endotracheal intubation for patients who had out-of-hospital emergencies. Both i-gels and King laryngeal tubes were reported as easier to insert than endotracheal intubation.
• As most identified studies focused on adults who had an OHCA, it is unclear if these findings are generalizable to other patient groups, including patients with other indications and pediatric patients. Few studies reported on adverse events, which may result in an overestimation of the benefits of extraglottic airway devices. The identified evidence-based guideline includes different recommendations for pediatric and adult patients, which indicates that other factors may influence which advanced airway management strategy is optimal.
• Decisions regarding the use of extraglottic airway devices may depend on specific patient factors (e.g., adult versus pediatric, cause of emergency), local factors (e.g., if paramedics can maintain proficiency in endotracheal intubation), and each management strategy’s training needs.