Abstract
IMPORTANCE: 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. OBJECTIVE: 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. DESIGN, SETTING, AND PARTICIPANTS: 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. EXPOSURES: Advanced airway devices documented by EMS clinicians. MAIN OUTCOME AND MEASURES: Order of advanced airway device use, measured by EMS clinician documentation. RESULTS: 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. CONCLUSIONS AND RELEVANCE: 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.