# Advanced Airway Device Use Order During Out-of-Hospital Cardiac Arrest

## TL;DR

This study examines how emergency medical services in the US use airway devices during out-of-hospital cardiac arrests, finding that supraglottic airways have higher success rates than endotracheal intubation.

## Contribution

The study reveals national patterns in airway device use and success rates during out-of-hospital cardiac arrests, emphasizing the impact of device order on outcomes.

## Key findings

- Endotracheal intubation (ETI) was more commonly used initially than supraglottic airway (SGA), but SGA had higher first-pass success rates.
- After a failed ETI attempt, most patients continued with ETI, while switching to SGA after a failed SGA attempt had higher final success rates.
- Most patients received a successful airway with a single advanced airway intervention.

## Abstract

What are national practice patterns in the order of advanced airway device use during adult out-of-hospital cardiac arrest (OHCA) among emergency medical service (EMS) activations?

In this cross-sectional study of 2 365 224 US EMS activations from 2018 to 2023, adult patients more commonly received endotracheal intubation (ETI) than supraglottic airway (SGA) as the initial advanced airway device. Most patients underwent single device placement, with SGA having higher initial and final device success rates.

In this study, most patients with OHCA received a successful airway with only a single advanced airway intervention, with SGAs having higher initial and final device success rates than ETI.

This cross-sectional study examines national patterns in the order in which emergency medical services clinicians use advanced airway support devices, namely endotracheal intubation and supraglottic airway, among US adults with out-of-hospital cardiac arrest.

During out-of-hospital cardiac arrest (OHCA), initial airway device choice as well as final device choice in the event of failure may both influence overall procedural success and patient outcomes. Understanding national practice patterns in airway device placement may inform resuscitation strategies and system-level quality improvement.

To assess patterns in the order of advanced airway device use for adults in the United States receiving OHCA treatment during emergency medical service (EMS) activations.

This retrospective cross-sectional study used data from the National EMS Information System (NEMSIS) database from January 2018 to December 2023. During this period, NEMSIS included more than 256 million EMS activations from nearly 14 000 agencies across 54 states and territories. Activations for 911 responses during adult OHCA with advanced airway device attempts after EMS arrival, with documented success (yes or no) and number of attempts, were included.

Advanced airway devices documented by EMS clinicians.

Order of advanced airway device use, measured by EMS clinician documentation.

From 2018 to 2023, EMS reported 2 365 224 activations involving adults having an OHCA, with 650 440 patients (0.3%) receiving either endotracheal intubation (ETI) and/or supraglottic airway (SGA). Most patients received a successful initial airway device attempt (503 774 [77.4%]). Although ETI was the most common initial airway device (458 546 [70.5%]), SGA had a higher first-pass success rate (93.0% vs 71.0%). Among patients whose first ETI attempt failed (133 177 of 458 546 [29.0%]), the final documented device remained ETI in 72 167 cases (72.3%) and changed to SGA in 27 651 (27.7%). Among patients whose first SGA attempt failed, 13 480 (61.9%) remained with SGA and 3388 (38.1%) were switched to ETI.

In this cross-sectional study, most patients with OHCA received ETI as the first advanced airway procedure, despite higher SGA first-pass success. Among patients whose initial attempt failed, most continued with the same device. However, switching from ETI to SGA had a higher final success rates. These findings highlight the importance of airway device sequence in prehospital care and may inform training and protocols for airway management.