Trends in Prehospital First-Attempt Use of Supraglottic Airways in Non-Cardiac Arrest Patients: A Descriptive Study

Objectives: This study aims to characterize the national prehospital trends in primary supraglottic airway use in non-cardiac arrest patients with various methods, including rapid sequence airway (RSA), defined as administration of a sedative and paralytic to facilitate supraglottic airway (SGA) placement. We compared this SGA-first practice to other methods of prehospital airway management. Methods: This was a retrospective analysis of a national emergency medical services (EMS) database containing 9-1-1 calls over a five-year period. Only ALS-level calls were included. We compared the incidence of SGA- and tracheal-intubation-first attempts by paramedics. We excluded interfacility transfers, patients in or near cardiac arrest, and surgical airways before intubation. Results: There were 355,511 encounters with endotracheal tube (ETT) or SGA placement, of which 316,392 patients were excluded, most commonly for cardiac arrest and peri-cardiac arrest, leaving 36,058 (92%) managed with tracheal intubation first and 3,061 (8%) managed with a SGA first. Trauma was the primary reason for encounter for approximately 28% of both groups. SGA-first approaches increased over the five-year period from 3.5% to 8.7% of invasive airway attempts. The type of SGA changed substantially over the study period, with use of the iGel increasing (42% to 82%), and the King LTSD decreasing (50% to 14%). Neuromuscular blocking agents were used in 74% of encounters. Conclusions: Among prehospital patients not in cardiac arrest, supraglottic airway devices comprise 8% of initial advanced airway management, with increasing use over time. Placement is usually facilitated by use of a sedative and neuromuscular blocking agent.