Cardiac Arrest Study: Supraglottic Airways Outperform Intubation

A national analysis reveals supraglottic devices offer higher first-pass success and better rescue rates than repeated intubation attempts

For Doctors in a Hurry

Researchers investigated national practice patterns regarding the sequence of advanced airway device placement during adult out-of-hospital cardiac arrest.
This retrospective cross-sectional study analyzed database records from 2018 to 2023, including 650,440 adults receiving advanced airway attempts.
Endotracheal intubation was the initial device for 70.5 percent, but <strong>supraglottic airways yielded higher first-pass success</strong> (93.0 percent versus 71.0 percent).
The researchers concluded that emergency clinicians predominantly initiate airway management with endotracheal intubation and usually continue the same device after failure.
Because switching to a supraglottic airway improved final success, these findings should inform prehospital airway management training and resuscitation protocols.

The Prehospital Airway Dilemma: Intubation Versus Supraglottic Devices

The optimal advanced airway strategy for out-of-hospital cardiac arrest remains an intensely debated topic among emergency and critical care physicians. While endotracheal intubation has historically served as the gold standard, recent randomized trials and meta-analyses suggest that supraglottic airway devices offer comparable or superior outcomes, including higher first-attempt success rates (up to 90.3% versus 51.6%) and improved 72-hour survival (18.3% versus 15.4%) [1], alongside a significantly higher likelihood of return of spontaneous circulation [2]. Despite these shifting paradigms and a notable surge in supraglottic airway utilization during the COVID-19 pandemic, where device usage increased from 12% to 37% [3], endotracheal intubation continues to be heavily favored by many emergency medical service agencies, accounting for over 71% of prehospital airways in recent international cohorts [4, 5]. However, when an initial airway attempt fails in the chaotic prehospital environment, the optimal sequence for subsequent rescue interventions remains poorly defined. A massive new nationwide analysis now offers fresh insights into how the specific sequence of airway device selection impacts procedural success in the field, providing critical data to help medical directors refine resuscitation protocols.

Mapping National Prehospital Airway Practices

To understand how prehospital airway management unfolds in real-world practice, researchers conducted a retrospective cross-sectional study (an observational analysis that captures a snapshot of data at a specific point in time) to assess patterns in the order of advanced airway device use for adults experiencing out-of-hospital cardiac arrest. The investigators utilized data from the National Emergency Medical Services Information System (NEMSIS) database spanning from January 2018 to December 2023. The sheer scale of this registry provides a comprehensive view of national practices, as NEMSIS included more than 256 million emergency medical service activations from nearly 14,000 agencies across 54 states and territories during this period. The researchers established strict inclusion criteria, isolating 911 responses for adult cardiac arrests that involved advanced airway device attempts after first responders arrived. By tracking both the documented success and the number of attempts, the methodology allowed investigators to map the exact sequence of interventions during complex resuscitations rather than just noting the initial device selected. Narrowing down the massive dataset, agencies reported 2,365,224 activations involving adults with an out-of-hospital cardiac arrest from 2018 to 2023. Within this broader pool, 650,440 patients (0.3% of all total database activations) received either endotracheal intubation or a supraglottic airway. By mapping the exact sequence of these interventions, the study provides a granular look at how frontline clinicians navigate airway management when initial strategies succeed or fail.

First-Pass Success: Supraglottic Airways Outperform Intubation

Securing an airway quickly is paramount during a cardiac arrest, and the data reveal a stark contrast between clinical preference and procedural efficacy. When analyzing the initial interventions, the researchers found that most patients received a successful initial airway device attempt, with 503,774 cases (77.4%) secured on the first try. Endotracheal intubation was the most common initial airway device, utilized in 458,546 cases (70.5%). Despite this heavy reliance on intubation, the data demonstrated that a supraglottic airway had a significantly higher first-pass success rate (93.0% versus 71.0%). The authors noted a clear clinical paradox: most patients received intubation as the first advanced airway procedure, despite the higher first-pass success of supraglottic devices. For practicing physicians and emergency medical directors, these findings underscore a critical opportunity to reevaluate prehospital protocols. The overwhelming default to intubation exposes nearly thirty percent of patients to a failed first attempt. In contrast, initiating airway management with a supraglottic device (such as a laryngeal mask airway or King tube, which sit above the vocal cords and require less technical visualization) could secure the airway on the first pass in over nine out of ten cases. This approach minimizes interruptions in chest compressions and reduces the risk of prolonged hypoxia during the most critical minutes of resuscitation.

The Rescue Strategy: What Happens When the First Attempt Fails?

When the first attempt at securing an airway is unsuccessful, frontline clinicians face a critical, time-sensitive decision that directly influences overall procedural success. The study revealed that among patients whose first endotracheal intubation attempt failed, a scenario that occurred in 133,177 of 458,546 cases (29.0%), the subsequent rescue choices dictated the ultimate success of the resuscitation. The researchers found that most clinicians continued with the same device rather than pivoting to an alternative strategy. Specifically, when the first intubation attempt failed, the final documented device remained an endotracheal tube in 72,167 cases (72.3%). In contrast, the final documented device changed to a supraglottic airway in only 27,651 cases (27.7%). A similar pattern of persistence was observed with supraglottic devices. Among patients whose first supraglottic attempt failed, 13,480 (61.9%) remained with the same device class, while 3,388 (38.1%) were switched to intubation. Despite the widespread tendency to repeat the same procedure, the data demonstrated that switching from endotracheal intubation to a supraglottic airway yielded higher final success rates. These findings highlight the vital importance of airway device sequencing in prehospital care, suggesting that a rapid transition to a supraglottic rescue device is clinically superior to repeated intubation attempts. For medical directors and emergency physicians, these insights should directly inform training and protocol development. Establishing clear algorithms that guide clinicians on exactly when to abandon a failed intubation and deploy a supraglottic airway will help minimize hypoxia and potentially improve survival outcomes for patients in cardiac arrest.

Study Info

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

Christopher B. Gage, Jacob C. Kamholz, Jonathan R. Powell, M. J. Nassal Michelle, et al.

Journal JAMA Network Open

Published January 12, 2026