Prehospital Airway Management: A Systematic Review

Abstract

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 and 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 and dual reviewed, data were abstracted, and studies were 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 low SOE 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 applicable only 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 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; SGA was better for multiple insertion attempts; and ETI was better for inadequate ventilation. Conclusions. The most common findings, across emergency types and age groups, were 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 as well as emergency medical services education and policy, and to improve patient-centered outcomes.

Algorithm to Improve Resuscitation Outcomes in Patients With Traumatic Out-of-Hospital Cardiac Arrest

“…A systemic review evaluated the benefits and harms of three airway management approaches (bag valve mask, supraglottic airway, and endotracheal intubation) used in prehospital settings on patients with TOHCA [ 13 ]. The review did not demonstrate that more invasive airway approaches improve survival and ROSC rates.…”

Prehospital airway management for out‐of‐hospital cardiac arrest: A nationwide multicenter study from the KoCARC registry

“…However, studies have reported mixed results regarding the application of AAM compared with bag-valvemask (BVM) ventilation. [1][2][3][4][5][6][7][8] It might be explained by the nonnegligible risk of failed AAM application, longer procedural time, lack of expertise required for AAM, [9][10][11] the need of interrupt chest compression, 12,13 or complications such as aspiration or regurgitation. 14 Study of a large-scale real-world data might clarify the clinical efficacy of prehospital AAM.…”

“…In the prehospital stage of out‐of‐hospital cardiac arrest (OHCA), securing oxygen supply and providing effective ventilation with the application of advanced airway managements (AAM) seems a reasonable and logical action. However, studies have reported mixed results regarding the application of AAM compared with bag–valve–mask (BVM) ventilation 1–8 . It might be explained by the nonnegligible risk of failed AAM application, longer procedural time, lack of expertise required for AAM, 9–11 the need of interrupt chest compression, 12,13 or complications such as aspiration or regurgitation 14 …”

Success Rate on Endotracheal Intubation with Prone versus Kneeling Position in Mannequin Model with Limitation of Neck Movement: A Cross Over Study

“…In some conditions, DL could be challenging from both anatomic and physiologic difficulties, which leads to a higher chance of failed intubation and worsening outcome. 7 , 8…”