27/01/2026
Let’s be honest about the culture from twenty years ago. Placing a supraglottic airway in a cardiac arrest was an admission of defeat. It was the clinical walk of shame. You only reached for a King or Combitube after you blew the tube. It meant you failed. You were a "rescue airway" medic. We tied our professional worth to passing plastic through cords. We ignored the physiology. We cared more about the optics of the skill than the perfusion of the patient. This study proves that the ghost of that mindset is still haunting our airway bags.
𝐒𝐓𝐎𝐏 𝐃𝐈𝐂𝐊𝐈𝐍𝐆 𝐀𝐑𝐎𝐔𝐍𝐃 𝐖𝐈𝐓𝐇 𝐓𝐇𝐄 𝐋𝐀𝐑𝐘𝐍𝐆𝐎𝐒𝐂𝐎𝐏𝐄 🛑
A massive 2026 retrospective study in JAMA Network Open analyzed over 650,000 adult cardiac arrests from the NEMSIS database. The numbers are aggressive. It demands a hard look in the mirror regarding our sequence of events.
𝐓𝐇𝐄 𝐃𝐀𝐓𝐀 𝐁𝐑𝐄𝐀𝐊𝐃𝐎𝐖𝐍 📊
Here is exactly what the numbers showed regarding practice patterns and success rates:
📉 We Are Creatures of Habit: Despite the evidence, we still chose intubation (ETI) first for 70.5% of patients.
🚫 The Failure Rate is High: First-pass success for intubation was only 71.0%. That means we botched the airway on nearly 30% of attempts.
✅ The SGA Dominance: In contrast, when medics chose a supraglottic airway (SGA) first, they achieved a 93.0% first-pass success rate.
𝐓𝐇𝐄 𝐃𝐄𝐅𝐈𝐍𝐈𝐓𝐈𝐎𝐍 𝐎𝐅 𝐈𝐍𝐒𝐀𝐍𝐈𝐓𝐘 📉
The most damning data points appeared when the first attempt failed. The study tracked what medics did after they missed the tube. This is where the "trajectory" of airway management matters more than the device itself:
🐢 The Stubborn Approach: Among patients where the first intubation attempt failed, 72.3% of medics kept trying to intubate. Their final success rate remained low at 70.5%. They fought the anatomy and lost.
🐇 The Smart Pivot: A smaller group (27.7%) recognized the failure and switched to an SGA. Their final success rate jumped to 94.1%.
Switching to an SGA after a failed tube was the single most effective salvage maneuver in the dataset. Yet the majority of us refused to do it.
𝐂𝐔𝐋𝐓𝐔𝐑𝐄 𝐕𝐒. 𝐄𝐕𝐈𝐃𝐄𝐍𝐂𝐄 🏛️
Why do we persist with a failing strategy? The authors point to deep-seated cultural factors. ETI is often viewed as a marker of clinical competence or an advanced skill. We rationalize it by citing aspiration risk, yet major trials like PART and AIRWAYS-2 found no clear difference in overall aspiration rates between the devices. We are letting tradition dictate care rather than the immediate needs of the patient.
𝐏𝐇𝐘𝐒𝐈𝐎𝐋𝐎𝐆𝐘 𝐎𝐕𝐄𝐑 𝐏𝐋𝐀𝐒𝐓𝐈𝐂 🫀
Pathophysiology dictates the priority. Cardiac arrest management is about flow. Every second you stop compressions to maximize your view is a second the coronary perfusion pressure tanks. It takes significant time and compressions to build that pressure back up.
Repeated laryngoscopy attempts destroy perfusion. They cause pauses. They distract the team leader.
The SGA fixes this. It seats in seconds. It seals. It minimizes gastric insufflation compared to a bag-valve-mask. It frees up your mental processor to manage the epinephrine, the electricity, and the crew resource management.
𝐓𝐇𝐄 𝐍𝐄𝐖 𝐒𝐓𝐀𝐍𝐃𝐀𝐑𝐃 🚨
Supraglottic airways should be the first-line intervention in cardiac arrest. Unless there is a hard contraindication or a compelling anatomical reason that absolutely demands a tube through the cords (like significant airway burns or massive trauma), the SGA is the superior choice. It is faster. It is safer. It is more successful. Make ETI the alternative, not the default.
𝐓𝐇𝐄 𝐈𝐍𝐓𝐄𝐍𝐓𝐈𝐕𝐈𝐒𝐓 𝐅𝐈𝐍𝐀𝐋 𝐓𝐇𝐎𝐔𝐆𝐇𝐓𝐒 💭
I have been that medic. I measured my shift by my tube confirmation. If I used a King airway, I felt like I hadn't done my job. That mindset was dangerous. It centered the care on me, not the patient. The patient does not care about your intubation stats. They care about oxygen to their brain. We need to evolve. Expert care is not forcing a procedure. Expert care is recognizing when a plan fails and pivoting immediately. Don't be the medic who prioritizes a plastic tube over a patient's life. Check your ego. Use the data. Save the brain.
REFERENCES📚
Gage CB, Kamholz JC, Powell JR, Nassal MMJ, Wang HE, Panchal AR. Advanced Airway Device Use Order During Out-of-Hospital Cardiac Arrest. JAMA Network Open. 2026;9(1):e2553413. doi:10.1001/jamanetworkopen.2025.53413
Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791. doi:10.1001/jama.2018.11597
Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044
