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Prehospital Airway Management

Written by Clay Smith

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There was no clear winner between bag valve mask (BVM), supraglottic airway (SGA), or endotracheal intubation (ETI) when patients needed ventilatory support or airway protection in the prehospital setting.

Why does this matter?
What are the best practices for prehospital airway management? The authors tackled 4 key questions, 3 of which were included in this paper.

EMS: BVM + SGA + ETT = no big differences

  • Design: This was a systematic review of 99 articles that answered 3 key questions. Some studies were RCTs, but most were observational and retrospective.

  • Q1 – BVM vs SGA: What are the comparative benefits and harms of BVM versus SGA for patients requiring prehospital ventilatory support or airway protection?

    • Survival: no difference

    • Neurological outcome: CPC score favors BVM

    • ROSC: no difference

    • Harms: no difference

  • Q2 – BVM vs ETI: What are the comparative benefits and harms of BVM versus ETI for patients requiring prehospital ventilatory support or airway protection?

    • Survival: no difference

    • Neuro outcome: no difference

    • ROSC: no difference

    • Harms: no difference

  • Q3 – SGA vs ETI: What are the comparative benefits and harms of SGA versus ETI for patients requiring prehospital ventilatory support or airway protection?

    • Survival: no difference

    • Neuro outcome: CPC score favors ETI

    • ROSC: favors SGA in adults, no difference in children

    • First-pass success: favors SGA in adults and children

    • Harms: ETI has greater insertion attempts; SGA has greater inadequate ventilation

  • Implications: Both BVM or SGA seem to be reasonable approaches in the prehospital setting for patients who need ventilatory support or airway protection. A SGA is certainly easier to insert.

  • Limitations: The strength of evidence for most studies was low. EMS skill levels and airway training varies considerably from one site to the next. Often EMS providers move from one airway intervention to the next as a backup, the nuance of which is not detectable in a registry database. Also, resuscitation time bias may be present. In other words, the patient’s status (response to CPR, etc) may determine the airway intervention and outcome rather than the other way around.

Source
Prehospital Airway Management: A Systematic Review. Prehosp Emerg Care. 2021 Jul 20;1-12. doi: 10.1080/10903127.2021.1940400. Online ahead of print.

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