Prehospital Airway Management: A Systematic Review

Project Summary Title and Description

Title
Prehospital Airway Management: A Systematic Review
Description
Objective. To assess the comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) by emergency medical services in the prehospital setting and how the benefits and harms differ based on patient characteristics, techniques, and devices. Data sources. We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020, reference lists, and posted a Federal Register notice request for data. Review methods. Review methods followed Agency for Healthcare Research and Quality Evidence-based Practice Center Program Methods guidance. Using pre-established criteria, studies were selected, dual reviewed, data abstracted, and evaluated for risk of bias. Meta-analyses using profile-likelihood random effects models were conducted when data were available from studies reporting on similar outcomes, with analyses stratified by study design, emergency type, and age. We qualitatively synthesized results when meta-analysis was not indicated. Strength of evidence (SOE) was assessed for primary outcomes (survival, neurological function, return of spontaneous circulation [ROSC], and successful advanced airway insertion [for SGA and ETI only]). Results. We included 99 studies (22 randomized controlled trials and 77 observational studies) involving 630,397 patients. Overall, we found few differences in primary outcomes when airway management approaches were compared. • For survival, there was moderate SOE for findings of no difference for BVM versus ETI in adult and mixed-age cardiac arrest patients. There was low SOE for no difference in these patients for BVM versus SGA and SGA versus ETI. There was low SOE for all three comparisons in pediatric cardiac arrest patients, and in adult trauma patients when BVM was compared with ETI. • For neurological function, there was moderate SOE for no difference for BVM compared with ETI in adults with cardiac arrest. There was low SOE for no difference in pediatric cardiac arrest for BVM versus ETI and SGA versus ETI. In adults with cardiac arrest, neurological function was better for BVM and ETI compared with SGA (both low SOE). • ROSC was only applicable in cardiac arrest. For adults, there was low SOE that ROSC was more frequent with SGA compared with ETI, and no difference for BVM versus SGA or BVM versus ETI. In pediatric patients there was also low SOE of no difference for BVM versus ETI and SGA versus ETI. • For successful advanced airway insertion, low SOE supported better first-pass success with SGA in adult and pediatric cardiac arrest patients and adult patients in studies that mixed emergency types. Low SOE also supported no difference for first-pass success in adult medical patients. For overall success, there was moderate SOE of no difference for adults with cardiac arrest, medical, and mixed emergency types. • While harms were not always measured or reported, moderate SOE supported all available findings. There were no differences in harms for BVM versus SGA or ETI. When SGA was compared with ETI, there were no differences for aspiration, oral/airway trauma, and regurgitation; multiple insertion attempts was better for SGA, and inadequate ventilation was better for ETI. Conclusions. The most common findings, across emergency types and age groups, was of no differences in primary outcomes when prehospital airway management approaches were compared. As most of the included studies were observational, these findings may reflect study design and methodological limitations. Due to the dynamic nature of the prehospital environment, the results are susceptible to indication and survival biases as well as confounding; however, the current evidence does not favor more invasive airway approaches. No conclusion was supported by high SOE for any comparison and patient group. This supports the need for high-quality randomized controlled trials designed to account for the variability and dynamic nature of prehospital airway management to advance and inform clinical practice, emergency medical services education and policy, and improve patient-centered outcomes.
Attribution
N/A
Authors of Report
N/A
Methodology description
Data sources. We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020, reference lists, and posted a Federal Register notice request for data. Review methods. Review methods followed Agency for Healthcare Research and Quality Evidence-based Practice Center Program Methods guidance. Using pre-established criteria, studies were selected, dual reviewed, data abstracted, and evaluated for risk of bias. Meta-analyses using profile-likelihood random effects models were conducted when data were available from studies reporting on similar outcomes, with analyses stratified by study design, emergency type, and age. We qualitatively synthesized results when meta-analysis was not indicated. Strength of evidence (SOE) was assessed for primary outcomes (survival, neurological function, return of spontaneous circulation [ROSC], and successful advanced airway insertion [for SGA and ETI only]).
PROSPERO
CRD42020170201
DOI
N/A
Notes
Appendix E. Study Characteristics Evidence Table https://srdr.s3.amazonaws.com/uploads/04-05-2021/Prehospital+Airway+Management+Study+Characteristics+Evidence+Table.xlsx Appendix F. Outcomes Evidence Table https://srdr.s3.amazonaws.com/uploads/04-05-2021/Prehospital+Airway+Management+Outcomes+Evidence+Table.xlsx
Funding Source
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center under contract for the Agency for Healthcare Research and Quality, Rockville, MD (Contract No. HHSA29022015000091)

Key Questions

1. a. What are the comparative benefits and harms of bag valve mask versus supraglottic airway for patients requiring prehospital ventilatory support or airway protection? b. Are the comparative benefits and harms modified by: i. Techniques or devices used? ii. Characteristics of emergency medical services personnel (including training, proficiency, experience, certification, licensure level, and/or scope of practice level)? iii. Patient characteristics?
2. a. What are the comparative benefits and harms of bag valve mask versus endotracheal intubation for patients requiring prehospital ventilatory support or airway protection? b. Are the comparative benefits and harms modified by: i. Techniques or devices used? ii. Characteristics of emergency medical services personnel (including training, proficiency, experience, certification, licensure level, and/or scope of practice level)? iii. Patient characteristics?
3. Key Question 3 a. What are the comparative benefits and harms of supraglottic airway versus endotracheal intubation for patients requiring prehospital ventilatory support or airway protection? b. Are the comparative benefits and harms modified by: i. Techniques or devices used? ii. Characteristics of emergency medical services personnel (including training, proficiency, experience, certification, licensure level, and/or scope of practice level)? iii. Patient characteristics?
4. What are the comparative benefits and harms of the following variations of any one of the three included airway interventions (bag valve mask, supraglottic airways, or endotracheal intubation) for patients requiring prehospital ventilatory support or airway protection: i. Techniques or devices used? ii. Characteristics of emergency medical services personnel (including training, proficiency, experience, certification, licensure level, and/or scope of practice level)? iii. Patient characteristics?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Use of an intubating laryngeal mask airway on out-of-hospital cardiac arrest patients in a developing emergency medical service system.2012
EMT-led laryngeal tube vs. face-mask ventilation during cardiopulmonary resuscitation - a multicenter prospective randomized trial.2017
Impact of prehospital airway management on combat mortality.2018
Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardiac arrest.2015
Comparison of arterial blood gases of laryngeal mask airway and bag-valve-mask ventilation in out-of-hospital cardiac arrests.2009
Prehospital endotracheal intubation for severe head injury in children: a reappraisal.2001
Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation.2004
Bag-Valve Mask versus Endotracheal Intubation in Out-of-Hospital Cardiac Arrest on Return of Spontaneous Circulation: A National Database Study.2020
A field comparison of the pharyngeotracheal lumen airway and the endotracheal tube.1992
An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways.2018
Effect of airway management strategies during resuscitation from out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.2020
Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.
The effect of Combitube use on paramedic experience in endotracheal intubation.2005
Introduction of the I-gel supraglottic airway device for prehospital airway management in a UK ambulance service.2014
Influence of prehospital airway management on neurological outcome in patients transferred to a heart attack centre following out-of-hospital cardiac arrest.2019
Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway.
Type of advanced airway and survival after pediatric out-of-hospital cardiac arrest.2020
Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?2019
Complication rates for the esophageal obturator airway and endotracheal tube in the prehospital setting.-- Not Found --
Airway management in out-of-hospital cardiac arrest in Finland: current practices and outcomes.2016
Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest.2011
Paramedic tracheal intubation using the intubating laryngeal mask airway.-- Not Found --
Multi-agency, prehospital evaluation of the pharyngeo-tracheal lumen (PTL) airway.-- Not Found --
Airway management and out-of-hospital cardiac arrest outcome in the CARES registry.2014
Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians.2003
Endotracheal intubation and esophageal tracheal Combitube insertion by regular ambulance attendants: a comparative trial.-- Not Found --
Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation.-- Not Found --
Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest.2012
The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury.2005
Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting.2014
A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury.2018
Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of out of hospital cardiac arrest: a feasibility study.2016
A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting.2006
First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study.2020
The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury.2005
Clinical evaluation of the use of laryngeal tube verses laryngeal mask airway for out-of-hospital cardiac arrest by paramedics in Singapore.2020
Endotracheal Intubation Success Rate in an Urban, Supervised, Resident-Staffed Emergency Mobile System: An 11-Year Retrospective Cohort Study.2020
The impact of rapid sequence intubation on trauma patient mortality in attempted prehospital intubation.2010
Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics.
Disposable stainless steel vs plastic laryngoscope blades among paramedics.2011
A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation.2017
First-Pass Success Intubations Using Video Laryngoscopy Versus Direct Laryngoscopy: A Retrospective Prehospital Ambulance Service Study.-- Not Found --
Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians.2009
The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke.2019
Use of the Airtraq® device for airway management in the prehospital setting--a retrospective study.2014
The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less.2017
First pass success of tracheal intubation using the C-MAC PM videolaryngoscope as first-line device in prehospital cardiac arrest compared with other emergencies: An observational study.2020
Out-of-hospital tracheal intubation with single-use versus reusable metal laryngoscope blades: a multicenter randomized controlled trial.2011
A comparison of plastic single-use with metallic reusable laryngoscope blades for out-of-hospital tracheal intubation.2007
EMS Intubation Improves with King Vision Video Laryngoscopy.2015
Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter, Randomized, Controlled Trial.2019
Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest.2013
Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy.2018
Increased First Pass Success with C-MAC Videolaryngoscopy in Prehospital Endotracheal Intubation-A Randomized Controlled Trial.2020
Higher insertion success with the i-gel supraglottic airway in out-of-hospital cardiac arrest: a randomised controlled trial.2014
Prehospital intubation in patients with severe head injury.2000
Determinants of Success and Failure in Prehospital Endotracheal Intubation.2016
A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success.-- Not Found --
Should laryngeal tubes or masks be used for out-of-hospital cardiac arrest patients?2015
Predictors of Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) Success in Traumatically Injured Patients Undergoing Prehospital Intubation.-- Not Found --
Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes.2016
The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.2014
Comparison of videolaryngoscopy and direct laryngoscopy by German paramedics during out-of-hospital cardiopulmonary resuscitation; an observational prospective study.2020
An assessment of paramedic performance during invasive airway management.-- Not Found --
Outcomes following prehospital airway management in severe traumatic brain injury.2013
The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients.
Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients.2015
Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial.2011
Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial.2016
How many attempts are required to accomplish out-of-hospital endotracheal intubation?2006
Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation.-- Not Found --
Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.2018
Analysis of prehospital care for cardiac arrest in an urban setting in Japan.2010
The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei.2018
The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest.-- Not Found --
Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study.2015
Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.2010
Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.2000
Effect of prehospital advanced life support on outcomes of major trauma patients.2000
Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial.2018
Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts.-- Not Found --
Association of patient age with first pass success in out-of-hospital advanced airway management.2019
Advanced airway management success rates in a national cohort of emergency medical services agencies.2020
Comparison of neurological outcome between tracheal intubation and supraglottic airway device insertion of out-of-hospital cardiac arrest patients: a nationwide, population-based, observational study.2013
King LT-D use by urban basic life support first responders as the primary airway device for out-of-hospital cardiac arrest.2011
Intubation techniques in the helicopter.-- Not Found --
Populations at risk for intubation nonattempt and failure in the prehospital setting.-- Not Found --
Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries.2016
Advanced airway management does not improve outcome of out-of-hospital cardiac arrest.2010
Prospective evaluation of airway management in pediatric out-of-hospital cardiac arrest.2020
A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database.2017
Prehospital endotracheal intubation and survival after out-of-hospital cardiac arrest: results from the Korean nationwide registry.2016
Effects of bag-mask versus advanced airway ventilation for patients undergoing prolonged cardiopulmonary resuscitation in pre-hospital setting.2012
Prognosis of patient with cardiopulmonary arrest transported to Kyushu University Hospital.2007
Effect of pre-hospital advanced airway management for out-of-hospital cardiac arrest caused by respiratory disease: a propensity score-matched study.2017
Out-of-hospital airway management and cardiac arrest outcomes: a propensity score matched analysis.2012
The impact of airway strategy on the patient outcome after out-of-hospital cardiac arrest: A propensity score matched analysis.2018
Tracheal intubation by paramedics under limited indication criteria may improve the short-term outcome of out-of-hospital cardiac arrests with noncardiac origin.2010

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