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Intubation

Date Last Search Run: Nov 12, 2019
Table last updated: Dec 18, 2019
Data last added: Apr 04, 2020


Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)
3 (weak evidence exists)    


Interventions

Bougie
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) First attempt ETI success Process ED-MD Driver BE., Prekker ME., Klein LR., Reardon RF., Miner JR., Fagerstrom ET., et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation A Randomized Clinical Trial. JAMA 2018; 319(21) 2179-89. Medline
I Supportive (Green) First pass success Process Sheu YJ, Yu SW, Huang TW, Liu FL, Lin YK, Tam KW. Comparison of the efficacy of a bougie and stylet in patients with endotracheal intubation: A meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2019 May;86(5):902-908. Medline
II Supportive (Green) First pass success Process Driver B., Dodd K., Klein LR., Buckley R., Robinson A., McGill JW., et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017; 70(4):473-8.e1. Medline
II Neutral (Yellow) Successful first attempt Patient ICU Heegaard WG., Black C., Pasquerella C., Miner J. Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting. Air Med J 2003; 22(1):28-31. Medline
III Supportive (Green) Success rate Process SIM Brazil V., Grobler C., Greenslade J., Burke J. Comparison of intubation performance by junior emergency department doctors using gum elastic bougie versus stylet reinforced endotracheal tube insertion techniques. Emerg Med Australas 2012; 24(2):194-200. Medline
III Supportive (Green) Successful airway management Process Combes X., Soupizet F., Jabre P., Margenet A., Marty J. Out of hospital difficult intubation resolved with nasotracheal use of a gum elastic bougie. Emerg Med J 2006; 23(8):e46. Medline
III Supportive (Green) Intubation success rate Process SIM Gataure PS. Simulated Difficult Intubation: Comparison of the Gum Elastic Bougie and the Stylet. Anesthesia 1996; 51:935-8. Medline
III Supportive (Green) Success rate, safety Process Jabre P., Combes X., Leroux B., Aaron E, Auger H, Margenet A, et al. Use of gum elastic bougie for prehospital difficult intubation. Am J Emerg Med 2005; 23(4):552-5. Medline
III Supportive (Green) Success rate Process SIM Messa MJ., Kupas DF., Dunham DL. Comparison of bougie-assisted intubation with traditional endotracheal intubation in a simulated difficult airway. Prehosp Emerg Care 2011; 15(1):30-3. Medline
III Supportive (Green) Successful Intubation Process ED-MD Moscati R., Jehle D., Christiansen G., et al. Endotracheal tube introducer for failed intubations: A variant of the gum elastic bougie. Ann Emerg Med 2000; 36(1):52-6. Medline
III Supportive (Green) Intubation success Process PH-Paramedic Nocera A. A flexible solution for emergency intubation difficulties. Ann Emerg Med 1996; 27(5):665-7. Medline
III Supportive (Green) Success rate Process SIM Phelan MP., Moscati R., D'Aprix T., Miller G. Paramedic use of the endotracheal tube introducer in a difficult airway model. Prehosp Emerg Care 2003; 7(2):244-6. Medline
III Supportive (Green) Successful intubation Patient ED-MD Sime J., Bailitz J., Moskoff J. The bougie: An inexpensive lifesaving airway device. J Emerg Med 2012; 43(6):e393-5. Medline
III Supportive (Green) Endotracheal intubation (ETI) attempts, success rates Patient Thomas S., Judge T., Lowell MJ., et al. Airway management success and hypoxemia rates in air and ground critical care transport: A prospective multicenter study. Prehosp Emerg Care 2010; 14(3):283. Medline
III Opposes (Red) Intubation within 30 sec Process SIM Gregory P., Woollard M., Lighton D., Munro G., Jenkinson E., Newcombe RG., et al. Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation. Anaesthesia 2012; 67(4):371-6. Medline
X Not Yet Graded (White) - Evrin T., Smereka J., Gorczyca D., Bialka S., Ladny JR., Katipoglu B., et al. Comparison of Different Intubation Methods in Difficult Airways during Simulated Cardiopulmonary Resuscitation with Continuous Chest Compression: A Randomized Cross-Over Manikin Trial. Emergency medicine international 2019; 7306204. Medline

Cricoid Pressure
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Rate of difficult laryngoscopy as defined by Cormack-Lehane. Process PH-MD & CCT Caruana E., Chevret S., Pirracchio R. Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis. EMJ 2017; 34(3):132-7. Medline
II Opposes (Red) Laryngeal view Process PH-MD & CCT Harris T., Ellis D., Foster L., Lockey D. Cricoid pressure and laryngeal manipulation in pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation? Resuscitation 2010; 81:810. Medline
III Opposes (Red) Target cricoid force Process ED-MD Clark RK., Trethewy CE. Assessment of cricoid pressure application by emergency department staff. Emerg Med Australas 2005; 17(4):376-81. Medline
III Opposes (Red) Detection trial intubation Process SIM Levitan RM., Kinkle WC., Levin WJ., Everett WW. Laryngeal view during laryngoscopy: A randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006; 47(6):548-55. Medline

Digital Intubation
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Intubation success Process ED-MD Cook RT. Jr., Polson DL. Use of BAAM with a digital intubation technique in a trauma patient. Prehosp Disaster Med 1993; 8(4):357-8. Medline
III Neutral (Yellow) Intubation success, number of attempts Process SIM Young S., et al. Is digital intubation an option for emergency physicians in definitive airway management? Am J Emerg Med 2006; 24:6:729-32. Medline

Direct Laryngoscopy (No airway reflexes)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Overall intubation success Process ED-MD Goksu E., Kilic T., Yildiz G., Unal A., Kartal M. Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED. Turkish journal of emergency medicine 2016; 16(2):53-56. Medline
I Supportive (Green) Favorable neurological outcome at 28 days Patient PH-MD & CCT Jabre P., Penaloza A., Pinero D. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018; 319(8):779-787 Medline
I Supportive (Green) Failure of attempted airway Process ED-MD Lewis SR., Butler AR., Parker J., Cook TM., Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. The Cochrane database of systematic reviews 2016; 11:CD011136. Medline
I Supportive (Green) Success rate Process PH-MD & CCT Trimmel H., Kreutziger J., Fertsak G., Fitzka R., Dittrich M., Voelckel WG. Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial. Crit Care Med 2011; 39(3):489-493. Medline
I Supportive (Green) Success Process PH-MD & CCT Trimmel H., Kreutziger J., Fitzka R., Szüts S., Derdak C., Koch E., et al. Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial. Crit Care Med 2016; 44(7):e470-6. Medline
I Neutral (Yellow) Modified Rankin Score at discharge or 30 days Patient PH-Paramedic Benger J., 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 Medline
I Neutral (Yellow) First pass success Process ED-MD Driver BE., Prekker ME., Moore JC., Schick AL., Reardon RF., Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Academic emergency medicine 2016; 23(4):433-9 Medline
I Neutral (Yellow) Success of airway management Patient PH-Paramedic Jensen JL., Cheung KW., Tallon JM., Travers AH. Comparison of tracheal intubation and alternative airway techniques performed in the prehospital setting by paramedics: A systematic review. CJEM 2010; 12(2):135-40. Medline
I Neutral (Yellow) Survival Patient PH-Paramedic Lecky F., Bryden D., Little R., Tong N., Moulton C. Emergency Intubation for acutely ill or injured patients. Cochrane Database of Systematic Reviews 2008; 2. Cochrane Library
I Opposes (Red) 72-hour survival Patient Wang H., Schmicker R., Daya M. 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. Medline
II Supportive (Green) EtCO2 during CPR Process Becker TK, Berning AW, Prabhu A, Callaway CW, Guyette FX, Martin-Gill C. An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways. Resuscitation 2018; 122:61-4. Medline
II Supportive (Green) ROSC, Survival to Discharge, Neuro intact Survival Patient PH-Paramedic Benoit JL., Gerecht RB., Steuerwald MT., McMullan JT. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation 2015; 93:20-6. Medline
II Supportive (Green) Survival to discharge Patient Chiang W., Hsieh M., Chu H., et al. The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei. Ann Emerg Med 2018; 71(3):387-96. Medline
II Supportive (Green) Intubation success, Oxygen saturation Process PH-Paramedic Davis DP., et al. Predictors of intubation success and therapeutic value of paramedic airway management in a large, urban EMS system. Prehosp Emerg Care 2006; 10:356-62. Medline
II Supportive (Green) Successful tube placement Process Dyson K., Bray JE., Smith K., Bernard S., Straney L., Nair R., et al. Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival. Ann Emerg Med 2017; 70(3):382-390 Medline
II Supportive (Green) Success rate Process Hiltunen P., Jäntti H., Silfvast T., Kuisma M., Kurola J. Airway management in out-of-hospital cardiac arrest in Finland: current practices and outcomes. Scandinavian journal of trauma, resuscitation and emergency medicine 2016;24:49. Medline
II Supportive (Green) Functionally favourable survival at one-month Patient PH-Paramedic Izawa J., Iwami T., Gibo K., Okubo M., Kajino K., Kiyohara K., et al. Timing of advanced airway management by emergency medical services personnel following out-of-hospital cardiac arrest A population-based cohort study. Resuscitation 2018; 128 16-23. Medline
II Supportive (Green) Multiple measures of chest compression interruptions Process Jarman AF., Hopkins CL., Hansen JN., Brown JR., Burk C., Youngquist ST. Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts. Prehosp Emerg Care 2017; 21(5):628-35. Medline
II Supportive (Green) First pass success Process Lee JK., Kang H., Choi HJ. Changes in the first-pass success rate with the GlideScope video laryngoscope and direct laryngoscope: a ten-year observational study in two academic emergency departments. Clinical and Experimental Emergency Medicine 2016; 3(4):213-218. Medline
II Supportive (Green) Intubation success rate Process PH-Paramedic Lossius HM., Roislien J., Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: A comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012; 16(1):R24. Medline
II Supportive (Green) First pass success Process Sakles JC., Mosier JM., Patanwala AE., Arcaris B., Dicken JM. The Utility of the C-MAC as a Direct Laryngoscope for Intubation in the Emergency Department. J Emerg Med 2016; 51(4):349-57. Medline
II Supportive (Green) 30-day survival Patient Sulzgruber P., Datler P., Sterz F., Poppe M., Lobmeyr E., Keferböck M., et al. The impact of airway strategy on the patient outcome after out-of-hospital cardiac arrest: A propensity score matched analysis. Eur Heart J Acute Cardiovasc Care 2018; 7(5):423-431. Medline
II Supportive (Green) Neurologically favorable 1-month survival Patient PH-Paramedic Tanabe S., Ogawa T., Akahane M., et al. Comparison of neurological outcome between tracheal intubation and supraglottic airway device insertion of out-of-hospital cardiac arrest patients: A nationwide, population-based, observational study. J Emerg Med 2013; 44(2):389-397. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Wang H., Szydlo D., Stouffer J., Lin S., Carlson J., Vaillancourt C., Sears G., Verbeek R., Fowler R., Idris R., Koenig K., Christenson J., Minokadeh A., Brandt J., Rea T. Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Resuscitation 2012; 83:1061-1066. Medline
II Supportive (Green) Successful ventilation Patient OR Winchell RJ., Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 1997; 132:592-597. Medline
II Neutral (Yellow) Successful placement Process PH-Paramedic Brown LH., Hubble MW., Wilfong DA., Hertelendy A., Benner RW. Airway management in the air medical setting. Air Med J 2011; 30(3):140-8. Medline
II Neutral (Yellow) Intubation success rate Process Crewdson K., Lockey DJ., Røislien J., Lossius HM., Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care 2017; 21(1):31. Medline
II Neutral (Yellow) Intubation success rate Process PH-Paramedic Garza AG., Gratton MC., Coontz D., Noble E., Ma OJ. Effect of paramedic experience on orotracheal intubation success rates. J Emerg Med 2003; 25:251-6. Medline
II Neutral (Yellow) Success rate Patient PH-Paramedic Hubble MW., Brown L., Wilfong DA., Hertelendy A., Benner RW., Richards ME. A meta-analysis of prehospital airway control techniques part I: Orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care 2010; 14(3):377-401. Medline
II Neutral (Yellow) One month survival with favorable neurological outcome Patient PH-Paramedic Kajino K., Iwami T., Kitamura T., et al. Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Crit Care 2011; 15(5):R236. Medline
II Neutral (Yellow) Sustained ROSC Patient PH-Paramedic McMullan J., Gerecht R., Bonomo .J, Robb R., McNally B., Donnelly J., Wang H. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation 2014; 85(5):617–22. Medline
II Neutral (Yellow) Intubation success rate Process Myers LA., Gallet CG., Kolb LJ., Lohse CM., Russi CS. Determinants of Success and Failure in Prehospital Endotracheal Intubation. The Western Journal of Emergency Medicine 2016; 17(5):640-7. Medline
II Neutral (Yellow) First-pass intubation success Process Savino PB., Reichelderfer S., Mercer MP., Wang RC., Sporer KA. Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis. Academic Emergency Medicine 2017; 24(8):1018-26. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Stiell IG., et al. Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. NEJM 2004; 351:647-56. Medline
II Neutral (Yellow) Rate of healing Process ED-MD Wang HE, Cook LJ, Change CCH, Yealy DM, Lave JR (2009). Outcomes after Out-of Hospital Endotracheal Intubation errors. Resus 80; 50-5. Medline
II Neutral (Yellow) Survival to discharge, 24-hour survival Patient In-Patient Wong ML., Carey S., Mader T., Wang HE., et al. Time to invasive airway placement and resuscitation outcomes after in-hospital cardiopulmonary arrest. Resusc 2010; 81(2):182-6. Medline
II Opposes (Red) Appropriate treatment Patient PH-Paramedic Bochicchio GV., Obeid I., Manjari J., Bochicchio K., Scalea T. Endotracheal Intubation in the Field Does Not Improve Outcome in Trauma Patients Who Present Without an Acutely Lethal Traumatic Brain Injury. J Trauma 2003; 54(2):307-11. Medline
II Opposes (Red) Long-term Survival Patient PH-Paramedic Fouche PF., Simpson PM., Bendall J., Thomas RE., Cone DC., Doi SA. Airways in out-of-hospital cardiac arrest: Systematic review and meta-analysis. Prehosp Emerg Care 2014; 18(2):244-56. Medline
II Opposes (Red) Favourable neurological outcome Patient PH-Paramedic Fukuda T., Fukuda-Ohashi N., Doi K., Matsubara T., Yahagi N. Effective pre-hospital care for out-of-hospital cardiac arrest caused by respiratory disease. Heart Lung Circ 2015; 24(3):241-9. Medline
II Opposes (Red) Survival to discharge Process PH-Paramedic Hanif MA., Kaji AH., Niemann JT. Advanced airway management does not improve outcome of out-of-hospital cardiac arrest. Acad Emerg Med 2010; 17(9):926-31. Medline
II Opposes (Red) Favourable neurological outcome 1 month Patient PH-Paramedic Hasegawa K., Hiraide A., Chang Y., Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013; 309(3):257-66. Medline
II Opposes (Red) Survival to discharge Patient Jeong S., Ahn KO., Shin SD. The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis. Am J Emerg Med 2016; 34(11):2101-2106. Medline
II Opposes (Red) Neurologically favourable survival at one month Patient Ohashi-Fukuda N., Fukuda T., Yahagi N. Effect of pre-hospital advanced airway management for out-of-hospital cardiac arrest caused by respiratory disease: a propensity score-matched study. Anaesth Intensive Care 2017; 45(3):375-83. Medline
II Opposes (Red) Symptom recovery Patient ED-MD Shafi S., Gentilello L. Prehospital endotracheal intubation and positive pressure ventilation in association with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the national trauma data bank. J Trauma 2005; (59)5:1140. Medline
II Opposes (Red) Survival Patient PH-Paramedic Wirtz DD., Ortiz C., Newman DH., Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007; 11:213-8. Medline
II Opposes (Red) Survival Patient PH-Paramedic Wirtz DD., Ortiz C., Newman DH., Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007; 11:213-8. Medline
III Supportive (Green) Rate of success, time to success Process SIM Bollig G., Lovhaug SW., Sagen O., Svendsen MV., Steen PA., Wik L. Airway management by paramedics using endotracheal intubation with a laryngoscope versus the oesophageal tracheal Combitube and EasyTube on manikins: a randomised experimental trial. Resuscitation 2006; 71(1):107-11. Medline
III Supportive (Green) Time to insertion, attempts Process SIM Calkins MD., Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma 1999; 46(5):927-32. Medline
III Supportive (Green) First Pass Success Process Ducharme S., Kramer B., Gelbart D., Colleran C., Risavi B., Carlson JN. A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation 2017; 114:121-126. Medline
III Supportive (Green) Time to intubation Process Gawlowski P., Smereka J., Madziala M., Cohen B., Ruetzler K., Szarpak L. Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics: A randomized crossover manikin trial. Medicine 2017; 96(16):e5873. Medline
III Supportive (Green) Success rates Process PH-Paramedic Jacobs LM., Berrizbeitia LD., Bennett B., et al. Endotracheal intubation in the prehospital phase of emergency medical care. JAMA 1983; 250:2175-7. Medline
III Supportive (Green) Intubation success Process SIM Komasawa N., Atagi K., Ueki R., Nishi S., Kaminoh Y., Tashiro C. Comparison of optic laryngoscope Airtraq((R)) and Miller laryngoscope for tracheal intubation during infant cardiopulmonary resuscitation. Resuscitation 2011; 82(6):736-9. Medline
III Supportive (Green) Intubation success Process SIM Nasim S., Maharaj CH., Malik MA., O'Donnell J., Higgins BD., Laffey JG. Comparison of the glidescope and pentax AWS laryngoscopes to the macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation. BMC Emerg Med 2009; 9:9-227X. Medline
III Supportive (Green) Success rate Process PH-Paramedic Pratt JC. Endotracheal Tube Placement by EMT-B in a Rural System. Prehospital Emerg Care 2005; 9(2):172-5. Medline
III Supportive (Green) Success Patient Swanson ER., Fosnocht DE., Matthews K., Barton ED. Comparison of the intubating laryngeal mask airway versus laryngoscopy in the bell 206-L3 EMS helicopter. Air Med J 2004; 23(1):36-39. Medline
III Supportive (Green) Endotracheal intubation (ETI) attempts, success rates Patient Thomas S., Judge T., Lowell MJ., et al. Airway management success and hypoxemia rates in air and ground critical care transport: A prospective multicenter study. Prehosp Emerg Care 2010; 14(3):283. Medline
III Supportive (Green) Time to ventilate after successful intubation Process SIM Ueshima H., Asai T. Tracheal intubation in daylight and in the dark: a randomised comparison of the Airway Scope, Airtraq, and Macintosh laryngoscope in a manikin. Anaesthesia 2010; 65(7):684-687. Medline
III Supportive (Green) Success Patient PH-Paramedic Wang HE., Kupas DF., Paris PM., Bates RR., Yealy DM. Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resus 2003; 58:49-58. Medline
III Supportive (Green) Success rate Process Yildirim A., Kiraz HA., Ağaoğlu, Akdur O. Comparison of Macintosh, McCoy and C-MAC D-Blade video laryngoscope intubation by prehospital emergency health workers: a simulation study. Intern Emerg Med 2017; 12(1):91-97. Medline
III Supportive (Green) Time to intubation Process Yousif S., Machan JT., Alaska Y., Suner S. Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment. Prehosp Disaster Med 2017; 32(4):352-356. Medline
III Neutral (Yellow) Description of clinical characteristics Patient Adnet F., Jouriles JN., Toumelin PL. Survey of out-of-hospital emergency intubations in the French prehospital medical system: A multicenter study. Ann Emerg Med 1998; 32:454-60. Medline
III Neutral (Yellow) Success rate, annual number of ETI per provider Process PH-Paramedic Burton JH., Baumann MR., Maoz T., Bradshaw JR., Lebrun JE. Endotracheal intubation in a rural EMS state: procedure utilization and impact of skills maintenance guidelines. Prehosp Emerg Care 2003; 7:352-6. Medline
III Neutral (Yellow) Successful intubation Process SIM Cinar O., Cevik E., Yildirim AO., Yasar M., Kilic E., Comert B. Comparison of GlideScope video laryngoscope and intubating laryngeal mask airway with direct laryngoscopy for endotracheal intubation. Eur J Emerg Med 2011; 18(2):117-20. Medline
III Neutral (Yellow) Success Process ED-MD Denver Metro Airway Study Group. A Prospective Multicentre Evaluation of Prehospital Airway Management in a Large Metropolitan Region. Prehospital Emergency Care 2009; 13(3):304-10. Medline
III Neutral (Yellow) First pass success rate Process Hafner JW., Perkins BW., Korosac JD., Bucher AK., Aldag JC., Cox KL. Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting. Air Med J 2016; 35(3):132-7. Medline
III Neutral (Yellow) Success rate of endotracheal intubation Process Kim JW., Park SO., Lee KR., Hong DY., Baek KJ., Lee YH., et al. Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Resuscitation 2016; 105:196-202. Medline
III Neutral (Yellow) Time to Intubation Process SIM Kim YM., Kang HG., Kim JH., Chung HS., Yim HW., Jeong SH. Direct versus video laryngoscopic intubation by novice prehospital intubators with and without chest compressions: A pilot manikin study. Prehosp Emerg Care 2011; 15(1):98-103. Medline
III Neutral (Yellow) Success Process PH-Paramedic Kurola J., et al. Airway management in cardiac arrest - comparison of LT, TI, BMV in emergency medical training. Resus 2005; 61:149-53. Medline
III Neutral (Yellow) Intubation success Process SIM Lewis AR., Hodzovic I., Whelan J., Wilkes AR., Bowler I., Whitfield R. A paramedic study comparing the use of the Airtraq, Airway Scope and Macintosh laryngoscopes in simulated prehospital airway scenarios. Anaesthesia 2010; 65(12):1187-93. Medline
III Neutral (Yellow) Resolution Patient ED-MD Liu L., Tanigawa K., Kusunoki S., Tamura T., Ota K., Yamaga S., et al. Tracheal intubation of a difficult airway using Airway Scope, Airtraq, and Macintosh laryngoscope: A comparative manikin study of inexperienced personnel. Anesth Analg 2010; 110(4):1049-55. Medline
III Neutral (Yellow) Success rate Process SIM Messa MJ., Kupas DF., Dunham DL. Comparison of bougie-assisted intubation with traditional endotracheal intubation in a simulated difficult airway. Prehosp Emerg Care 2011; 15(1):30-3. Medline
III Neutral (Yellow) Success rate Process Pieters BM., Wilbers NE., Huijzer M., Winkens B., van Zundert AA. Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel. Anaesthesia 2016; 71(5):556-64. Medline
III Neutral (Yellow) Time to placement Process SIM Southard A., Braude D., Crandall C. Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew. Resuscitation 2010; 81(5):576-578. Medline
III Neutral (Yellow) Time to intubation Process Truszewski Z., Czyzewski L., Smereka J., Krajewski P., Fudalej M., Madziala M., et al. Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes. Am J Emerg Med 2016; 34(9):1835-9. Medline
III Neutral (Yellow) Functional of-hospital airway management in the United States Patient PH-Paramedic Wang HE., Mann NC., Mears G., Jacobson K., Yealy D. Out-of-hospital airway management in the United States. Resuscitation 2011; 82(4):378–385. Medline
III Neutral (Yellow) Number of attempts to intubate Patient PH-Paramedic Wang HE., Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation? Acad Emer Med 2006; 13(4):372-7. Medline
III Neutral (Yellow) Reduction in no flow time Patient SIM Wiese CH., Bartels U., Bergmann A., Bergmann I., Bahr J., Graf BM. Using a laryngeal tube during cardiac arrest reduces "no flow time" in a manikin study: A comparison between laryngeal tube and endotracheal tube. Wien Klin Wochenschr 2008; 120(7-8):217-223. Medline
III Neutral (Yellow) intubation success Process SIM Wik L., Naess AC., Steen PA. Intubation with laryngoscope versus transillumination performed by paramedic students on manikins and cadavers. Resuscitation 1997; 33(3):215-218. Medline
III Neutral (Yellow) First pass success Process ED-MD Wollard M. et al. Airtraq vs. standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation. Anaesth 2008; 63:26-31. Medline
III Neutral (Yellow) Time to successful ventilation Process SIM Yun BJ., Brown CA.,3rd, Grazioso CJ., Pozner CN., Raja AS. Comparison of video, optical, and direct laryngoscopy by experienced tactical paramedics. Prehosp Emerg Care 2014; 18(3):442-445. Medline
X Not Yet Graded (White) - Arulkumaran N., Lowe J., Ions R., Mendoza M., Bennett V., Dunser MW. Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth 2018; 120(4):712-24. Medline
X Not Yet Graded (White) - Bhattacharjee S., Maitra S., Baidya DK. A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials. J Clin Anesth 2018; 47:21-6. Medline
X Not Yet Graded (White) - Edwards T., Williams J., Cottee M. Influence of prehospital airway management on neurological outcome in patients transferred to a heart attack centre following out-of-hospital cardiac arrest. EMA 2019; 31(1):76-82. Medline
X Not Yet Graded (White) - Fouche PF., Smith K., Jennings PA., Boyle M., Bernard S. The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke. EMJ 2019; 36(7):416-22. Medline
X Not Yet Graded (White) - Granfeldt A., Avis SR., Nicholson TC., Holmberg MJ., Moskowitz A., Coker A., et al. Advanced airway management during adult cardiac arrest: A systematic review. Resuscitation 2019; 139:133-43. Medline
X Not Yet Graded (White) - Hale JJ., Lynch S., Ray DC., Reid LA., . Adolescent tracheal intubation in an adult urban emergency department a retrospective, observational study. European journal of emergency medicine 2017; 24(6) e6-10. Medline
X Not Yet Graded (White) - Izawa J., Komukai S., Gibo K., Okubo M., Kiyohara K., Nishiyama C., et al. Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study. BMJ (Clinical research ed) 2019; 364:l430. Medline
X Not Yet Graded (White) - Wang CH, Lee AF, Chang WT, et al. Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials [published online ahead of print, 2020 Jan 23]. Ann Emerg Med. 2020;S0196-0644(19)31434-9. doi:10.1016/j.annemergmed.2019.12.003 Medline

Direct Laryngoscopy (with airway reflexes)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Success Process Trimmel H., Kreutziger J., Fitzka R., Szüts S., Derdak C., Koch E., et al. Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial. Crit Care Med 2016; 44(7):e470-6. Medline
I Neutral (Yellow) Success Process OR Avidan MS., Harvey A., Chitkara N., Ponte J. The intubating laryngeal mask airway compared with direct laryngoscopy. Br J Anaesth 1999; 83(4):615-7. Medline
I Neutral (Yellow) Ease and speed of placement Process OR Brimacombe J. The advantages of the LMA over the tracheal tube or facemask: a meta-analysis. Can J Anaesth 1995; 42(11):1017-23. Medline
I Neutral (Yellow) intubation time Process OR Chalkeidis O., Kotsovolis G., Kalakonas A., Filippidou M., Triantafyllou C., Vaikos D., et al. A comparison between the Airtraq and Macintosh laryngoscopes for routine airway management by experienced anesthesiologists: a randomized clinical trial. Acta Anaesthesiol Taiwan 2010; 48(1):15-20. Medline
I Neutral (Yellow) First pass success Process Driver BE., Prekker ME., Moore JC., Schick AL., Reardon RF., Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Academic emergency medicine 2016; 23(4):433-9 Medline
I Neutral (Yellow) intubation success after three attempts Patient OR Hung OR., Pytka S., Morris I., Murphy M., Launcelott G., Stevens S., et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995; 83(3):509-14. Medline
I Neutral (Yellow) Success of airway management Patient PH-Paramedic Jensen JL., Cheung KW., Tallon JM., Travers AH. Comparison of tracheal intubation and alternative airway techniques performed in the prehospital setting by paramedics: A systematic review. CJEM 2010; 12(2):135-40. Medline
I Neutral (Yellow) Failure of attempted airway Process Lewis SR., Butler AR., Parker J., Cook TM., Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. The Cochrane database of systematic reviews 2016; 11:CD011136. Medline
I Neutral (Yellow) Increase in size of intracranial hemorrhage Patient ED-MD Yu SH., Beirne OR. Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review. J Oral Maxillofac Surg 2010; 68(10):2359-2376. Medline
II Supportive (Green) Intubation success rate Process Crewdson K., Lockey DJ., Røislien J., Lossius HM., Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care 2017; 21(1):31. Medline
II Supportive (Green) successful tracheal intubation (with first device) Process ED-MD Michailidou M., O'Keeffe T., Mosier JM., et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg 2015; 39(3):782-8. Medline
II Supportive (Green) Number of attempts to intubate Patient PH-Paramedic Wayne MA., McDonnell M. Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation. Prehosp Emerg Care 2010; 14(2):278-282. Medline
II Neutral (Yellow) Successful placement Process PH-Paramedic Brown LH., Hubble MW., Wilfong DA., Hertelendy A., Benner RW. Airway management in the air medical setting. Air Med J 2011; 30(3):140-8. Medline
II Neutral (Yellow) Success, time Process OR Cavus E., Deitmer W., Francksen H., Serocki G., Bein B., Scholz J., et al. Laryngeal tube S II, ProSeal laryngeal mask, and EasyTube during elective surgery: a randomized controlled comparison with the endotracheal tube in nontrained professionals. Eur J Anaesthesiol 2009; 26(9):730-35. Medline
II Neutral (Yellow) Prehospital time delay Process PH-Paramedic Cudnik MT., Newgard CD., Wang H., Bangs C., Herrington R. Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emer Care 2007; 11:224-9. Medline
II Neutral (Yellow) Mortality Patient Fevang E., Perkins Z., Lockey D., Jeppesen E., Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care 2017; 21(1):192. Medline
II Neutral (Yellow) Success rate Patient PH-Paramedic Hubble MW., Brown L., Wilfong DA., Hertelendy A., Benner RW., Richards ME. A meta-analysis of prehospital airway control techniques part I: Orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care 2010; 14(3):377-401. Medline
II Neutral (Yellow) Hospital mortality Patient PH-Paramedic Kempema J., Trust MD., Ali S., et al. Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma. Am J Emerg Med 2015; 33(8):1080-3. Medline
II Neutral (Yellow) Intubation success rate Process PH-Paramedic Lossius HM., Roislien J., Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: A comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012; 16(1):R24. Medline
II Neutral (Yellow) Intubation success rate Process Myers LA., Gallet CG., Kolb LJ., Lohse CM., Russi CS. Determinants of Success and Failure in Prehospital Endotracheal Intubation. The Western Journal of Emergency Medicine 2016; 17(5):640-7. Medline
II Neutral (Yellow) Efficacy Process OR Nishikawa K., Kawana S., Namiki A. Comparison of the lightwand technique with direct laryngoscopy for awake endotracheal intubation in emergency cases. J Clin Anesth 2001; 13(4):259-63. Medline
II Opposes (Red) Intubation success, Oxygen saturation Process PH-Paramedic Davis DP., et al. Predictors of intubation success and therapeutic value of paramedic airway management in a large, urban EMS system. Prehosp Emerg Care 2006; 10:356-62. Medline
II Opposes (Red) Complications Patient PH-Paramedic & MD Ono Y., Kakamu T., Kikuchi H., Mori Y., Watanabe Y., Shinohara K. Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department. Emergency medicine international 2018; 2018 5649476. Medline
II Opposes (Red) Survival Patient PH-Paramedic Stiell IG., et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008; 178:1141-52. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Stockinger ZT., McSwain NE. Prehospital Endotracheal Intubation for Trauma does not improve survival over bag-mask ventilation. J Trauma 2004; 56:531-6. Medline
III Supportive (Green) Success Patient PH-Paramedic Wang HE., Kupas DF., Paris PM., Bates RR., Yealy DM. Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resus 2003; 58:49-58. Medline
III Neutral (Yellow) Functional of-hospital airway management in the United States Patient PH-Paramedic Wang HE., Mann NC., Mears G., Jacobson K., Yealy D. Out-of-hospital airway management in the United States. Resuscitation 2011; 82(4):378–385. Medline
III Opposes (Red) Sensitivity and specificity Process PH-Paramedic Pelucio M., Halligan L., Dhindsa H. Out-of-hospital experience with the syringe esophageal detector device. Acad Emerg Med 1997; 4:563-8. Medline
X Not Yet Graded (White) - Fouche PF., Smith K., Jennings PA., Boyle M., Bernard S. The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke. EMJ 2019; 36(7):416-22. Medline

ETI via a SGA device
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Success Process OR Avidan MS., Harvey A., Chitkara N., Ponte J. The intubating laryngeal mask airway compared with direct laryngoscopy. Br J Anaesth 1999; 83(4):615-7. Medline
II Supportive (Green) Time to intubation and success rate. Process SIM Kim JG., Kim W., Kang GH., Jang YS., Choi HY., Kim H., et al. Pre-hospital i-gel blind intubation for trauma a simulation study. Clinical and experimental emergency medicine 2018; 5(1) 29-34. Medline
II Supportive (Green) Success rate Process PH-Paramedic McCall M., et al. Paramedic tracheal intubations using the I-LMA. Prehosp Emerg Care 2008; 12:30-4. Medline
III Supportive (Green) Successful airway management Process Combes X., Jabre P., Ferrand E., Marty J. Out-of-hospital use of intubating laryngeal mask airway for difficult intubation caused by cervical dislocation. EMJ 2007; 24:e27. emj online
III Supportive (Green) Success rate Process OR Ferson DZ., et al. Use of the Intubating LMA-Fastrach & Trade; in 254 Patients with Difficult-to-manage Airways. Anesthesiology 2001; 95(5). Medline
III Supportive (Green) Time to insertion Process Gawlowski P., Smereka J., Madziala M., Szarpak L., Frass M., Robak O. Comparison of the Macintosh laryngoscope and blind intubation via the iGEL for Intubation With C-spine immobilization: A Randomized, crossover, manikin trial. Am J Emerg Med 2017; 35(3):484-487. Medline
III Supportive (Green) Successful endotracheal intubation Process SIM Menzies R., Manji H. The intubating laryngeal mask: Is there a role for paramedics? Emerg Med J 2007; 24(3):198-9. Medline
III Supportive (Green) Success Patient Swanson ER., Fosnocht DE., Matthews K., Barton ED. Comparison of the intubating laryngeal mask airway versus laryngoscopy in the bell 206-L3 EMS helicopter. Air Med J 2004; 23(1):36-39. Medline
III Supportive (Green) Efficacy Process ED-MD Tentillier E., et al. Use of the intubating LMA in emergency pre-hospital difficult intubation. Resus 2008; 77:30-4. Medline

Laryngeal Manipulation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Laryngeal view Process Harris T., Ellis D., Foster L., Lockey D. Cricoid pressure and laryngeal manipulation in pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation? Resuscitation 2010; 81:810. Medline
III Supportive (Green) Inter-rater agreement Process ED-MD Levitan RM., Kinkle WC., Levin WJ., Everett WW. Laryngeal view during laryngoscopy: A randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006; 47(6):548-55. Medline
III Neutral (Yellow) Single attempt ETI success rate Process SIM Samuel N., Winkler K., Peled S., Krauss B., Shavit I. External laryngeal manipulation does not improve the intubation success rate by novice intubators in a manikin study. Am J Emerg Med 2012; 30(9):2005-10. Medline

Lighted Stylet
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Intubation success after three attempts Patient OR Hung OR., Pytka S., Morris I., Murphy M., Launcelott G., Stevens S., et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995; 83(3):509-14. Medline
II Supportive (Green) Efficacy Process OR Nishikawa K., Kawana S., Namiki A. Comparison of the lightwand technique with direct laryngoscopy for awake endotracheal intubation in emergency cases. J Clin Anesth 2001; 13(4):259-63. Medline
III Supportive (Green) Success rate Process SIM MacNab AJ., MacPhail I., MacNab MK., Noble R., O'Flaherty D. A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets. Paediatr Anaesth 1998; 8(3):215-20. Medline
III Opposes (Red) Success rate Process SIM Margolis GS., Menegazzi J., Abdlehak M., Delbridge TR. The efficacy of a standard training program for transillumination-guided endotracheal intubation. Acad Emerg Med 1996; 3(4):371-7. Medline
III Opposes (Red) Intubation success Process SIM Wik L., Naess AC., Steen PA. Intubation with laryngoscope versus transillumination performed by paramedic students on manikins and cadavers. Resuscitation 1997; 33(3):215-218. Medline

Nasotracheal intubation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Complications Patient Jazayeri-Moghaddas OP., Tse W., Herzing KA., Markert RJ., Gans AJ., McCarthy MC. Is nasotracheal intubation safe in facial trauma patients? Am J Surg 2017; 213(3):572-4. Medline
II Supportive (Green) Intubation success Patient PH-Paramedic Weitzel N., Kendall J., Pons P. Blind nasotracheal intubation for patients with penetrating neck trauma. J Trauma 2004; 56(5):1097-1101. Medline
II Neutral (Yellow) Success Process PH-Paramedic Brown J., Thomas F. What happens with failed blind nasal tracheal intubations? Air Med J 2001; 20(2):13-6. Medline
II Neutral (Yellow) Success rate Patient PH-Paramedic Hubble MW., Brown L., Wilfong DA., Hertelendy A., Benner RW., Richards ME. A meta-analysis of prehospital airway control techniques part I: Orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care 2010; 14(3):377-401. Medline
II Neutral (Yellow) Complications Patient Jazayeri-Moghaddas OP., Tse W., Herzing KA., Markert RJ., Gans AJ., McCarthy MC. Is nasotracheal intubation safe in facial trauma patients? Am J Surg 2017; 213(3):572-4. Medline
II Neutral (Yellow) ETI success rate Process PH-Paramedic O'Connor RE., Megargel RE., Schnyder ME., Madden JF., Bitner M., Ross R. Paramedic success rate for blind nasotracheal intubation is improved with the use of an endotracheal tube with directional tip control. Ann Emerg Med 2000; 36(4):328-32. Medline
II Neutral (Yellow) Use of DFI (drug-facilitated intubation) Patient PH-Paramedic Wang HE., Kupas DF., Paris PM., Yealy DM. Factors associated with the use of pharmacologic agents to facilitate out-of-hospital endotracheal intubation. Prehosp Emerg Care 2004; 8(1):1-9. Medline
II Opposes (Red) Successful placement Process PH-Paramedic Brown LH., Hubble MW., Wilfong DA., Hertelendy A., Benner RW. Airway management in the air medical setting. Air Med J 2011; 30(3):140-8. Medline
III Supportive (Green) Endotracheal intubation (ETI) attempts, success rates Patient Thomas S., Judge T., Lowell MJ., et al. Airway management success and hypoxemia rates in air and ground critical care transport: A prospective multicenter study. Prehosp Emerg Care 2010; 14(3):283. Medline
III Neutral (Yellow) Success Process Dubey PK., Dubey P., Kumar N., Bhardwaj G., Kumar N. Blind Nasal Intubation Revisited: No Longer a Blind Technique? J Emerg Med 2017; 52(2):231-234. Medline
III Neutral (Yellow) ETI success rate Process PH-Paramedic Rhee K., O'Malley R. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med 1994; 23:37-42. Medline

NO DESAT/Nasal apneic oxygenation
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Lowest oxygen saturation Patient Caputo N., Azan B., Domingues R., Donner L., Fenig M., Fields D., et al. EmergeNcy Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). Acad Emerg Med 2017; 24(11):1387-94. Medline
II Supportive (Green) Incidence of desaturation Patient Binks MJ., Holyoak RS., Melhuish TM., Vlok R., Bond E., White LD. Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis. Am J Emerg Med 2017; 35(10):1542-6. Medline
II Supportive (Green) Incidence of desaturation Patient Doyle AJ., Stolady D., Mariyaselvam M., Wijewardena G., Gent E., Blunt M., et al. Preoxygenation and apneic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for emergency intubation. J Crit Care 2016;36:8-12. Medline
II Supportive (Green) Single-breath exhalation end-tidal oxygen Patient Hayes-Bradley C., Lewis A., Burns B., Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med 2016; 68(2):174-80. Medline
II Supportive (Green) Rate of peri-intubation hypoxia Process PH-Paramedic Jarvis JL., Gonzales J., Johns D., Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med 2018; 72(3) 272-9.e1. Medline
II Supportive (Green) Lowest SpO2 peri intubation Patient Oliveira JE., Silva L., Cabrera D., Barrionuevo P., Johnson RL., Erwin PJ., Murad MH., et al. Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-analysis. Ann Emerg Med 2017; 70(4):483-494. Medline
II Supportive (Green) Clinically significant hypoxemia Patient Pavlov I., Medrano S., Weingart S. Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Am J Emerg Med 2017; 35(8):1184-9. Medline
II Supportive (Green) First pass success without hypoxemia Process Sakles JC., Mosier JM., Patanwala AE., Arcaris B., Dicken JM. First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department. Academic Emergency Medicine 2016; 23(6):703-10. Medline
II Supportive (Green) Hypoxemia Patient Sakles JC., Mosier JM., Patanwala AE., Dicken JM. Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department. Internal and Emergency Medicine 2016; 11(7):983-92. Medline
II Supportive (Green) Hypoxemia Patient White LD., Melhuish TM., White LK., Wallace LA. Apnoeic oxygenation during intubation: a systematic review and meta-analysis. Anaesth Intensive Care 2017; 45(1):21-27. Medline
II Neutral (Yellow) Effectiveness in preventing hypoxemia Process Riyapan S., Lubin J. Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study. Air Med J 2016; 35(6):365-8. Medline
III Supportive (Green) Mean Fe02 Patient Driver BE., Prekker ME., Kornas RL., Cales EK., Reardon RF. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med 2017; 69(1):1-6. Medline
X Not Yet Graded (White) - Caputo N., Azan B., Domingues R., Donner L., Fenig M., Fields D., et al. Emergency Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation A Randomized Controlled Trial (The ENDAO Trial). Academic emergency medicine 2017; 24(11) 1387-94. Medline

Optical (non-video) Visualization (e.g. Airtraq)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Duration of the tracheal intubation Process OR Maharaj CH., Costello JF., Harte BH., Laffey JG. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation. Anaesthesia 2008; 63:182-8. Medline
I Neutral (Yellow) Intubation time Process OR Chalkeidis O., Kotsovolis G., Kalakonas A., Filippidou M., Triantafyllou C., Vaikos D., et al. A comparison between the Airtraq and Macintosh laryngoscopes for routine airway management by experienced anesthesiologists: a randomized clinical trial. Acta Anaesthesiol Taiwan 2010; 48(1):15-20. Medline
I Neutral (Yellow) Duration of the tracheal intubation Process OR Maharaj CH., O'Croinin D., Curley G., Harte BH., Laffey JG. A comparison of tracheal intubation using the Airtraq or the Macintosh laryngoscope in routine airway management: A randomised, controlled clinical trial. Anaesthesia 2006; 61:1093-9. Medline
I Opposes (Red) Success rate Process Trimmel H., Kreutziger J., Fertsak G., Fitzka R., Dittrich M., Voelckel WG. Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial. Crit Care Med 2011; 39(3):489-493. Medline
III Supportive (Green) Intubation Success Process PH-Paramedic Black JJM. Emergency use of the Airtraq laryngoscope in traumatic asphyxia. Emerg Med J 2007; 24:509-10. Medline
III Supportive (Green) Success rate Process El-Boghdadly K., Onwochei DN., Cuddihy J., Ahmad I. A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre. Anaesthesia 2017;72(6):694-703. Medline
III Supportive (Green) Intubation success Process SIM Lewis AR., Hodzovic I., Whelan J., Wilkes AR., Bowler I., Whitfield R. A paramedic study comparing the use of the Airtraq, Airway Scope and Macintosh laryngoscopes in simulated prehospital airway scenarios. Anaesthesia 2010; 65(12):1187-93. Medline
III Supportive (Green) Intubation success Process SIM Liu L., Tanigawa K., Kusunoki S., Tamura T., Ota K., Yamaga S., et al. Tracheal intubation of a difficult airway using Airway Scope, Airtraq, and Macintosh laryngoscope: A comparative manikin study of inexperienced personnel. Anesth Analg 2010; 110(4):1049-55. Medline
III Supportive (Green) Intubation success Process SIM Nasim S. Comparison of Airtraq and Truview Laryngoscopes to the Macintosh Laryngoscope for use by ACPs in Easy and Simulated Difficult Intubation in Manikins. BMC 2009; 9:2. BMC
III Supportive (Green) reduction in acute agitation Patient In-Patient Nowicki TA., et al. Comparison of use of the airtraq with direct laryngoscopy by paramedics in the simulated airway. Prehosp Emerg Care 2009; 13:75-80. Medline
III Supportive (Green) Time to ventilate after successful intubation Process SIM Ueshima H., Asai T. Tracheal intubation in daylight and in the dark: a randomised comparison of the Airway Scope, Airtraq, and Macintosh laryngoscope in a manikin. Anaesthesia 2010; 65(7):684-687. Medline
III Supportive (Green) First pass success Process ED-MD Wollard M. et al. Airtraq vs. standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation. Anaesth 2008; 63:26-31. Medline
III Neutral (Yellow) Success rate Process SIM Amathieu R., Sudrial J., Abdi W., Luis D., Hahouache H., Combes X., et al. Simulating face-to-face tracheal intubation of a trapped patient: a randomized comparison of the LMA Fastrach™, the GlideScope™, and the Airtraq™ laryngoscope. Br J Anaesth 2012; 108(1):140-5. Medline
III Neutral (Yellow) ETI success rate Patient OR Putz L., Dangelser G., Constant B., Jamart J., Collard E., Maes M., et al. Prospective trial comparing Airtraq and Glidescope techniques for intubation of obese patients. Ann Fr Anesth Reanim 2012; 31(5):421-6. Medline
III Neutral (Yellow) Success of laryngeal intubation. Patient SIM Wackett A., Anderson K., Thode H. Bullard laryngoscopy by naive operators in the cervical spine immobilized patient. J Emerg Med 2005; 29(3):253-257. Medline
III Neutral (Yellow) Time to successful ventilation Process SIM Yun BJ., Brown CA.,3rd, Grazioso CJ., Pozner CN., Raja AS. Comparison of video, optical, and direct laryngoscopy by experienced tactical paramedics. Prehosp Emerg Care 2014; 18(3):442-445. Medline

Oxymetry Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Incidence of hypoxemia in emergency intubations. Patient ED-MD Mateer JR., Olson DW., Stueven HA., Aufderheide TP. Continuous pulse oximetry during emergency endotracheal intubation. Ann Emerg Med 1993; 22(4):675-9. Medline
X Not Yet Graded (White) - Alwadhi V., Dewan P., Malhotra RK., Shah D., Gupta P. Tachypnea and Other Danger Signs vs Pulse Oximetry for Prediction of Hypoxia in Severe Pneumonia/Very Severe Disease. Indian Pediatr 2017; 54(9):729-34. Medline

Securing tube
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Rate of stroke thrombolysis Process PH-Paramedic Kupas DF., Kauffman KF., Wang HE. Effect of airway-securing method on prehospital endotracheal tube dislodgment. Prehosp Emerg Care 2010; 14(1):26-30. Medline
III Supportive (Green) Time to application/ Fixation Process SIM Luria S., Vidan A., Nahtomi O., Khanin A., Alcalay M. Proposed technique for evaluation of endotracheal tube fixation and comparison of four fixation methods. Mil Med 2001; 166(1):82-4. Medline
III Supportive (Green) Tube movement (mm) Process SIM Murdoch E., Holdgate A. A comparison of tape-tying versus a tube-holding device for securing endotracheal tubes in adults. Anaesth Intensive Care 2007; 35(5):730-5. Medline
III Supportive (Green) Force needed to extubate Process SIM Owen R., Castle N., Hann H., Reeves D., Naidoo R., Naidoo S. Extubation force: A comparison of adhesive tape, non-adhesive tape and a commercial endotracheal tube holder. Resuscitation 2009; 80(11):1296-300. Medline

Video Visualization ( e.g. Glidescope)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Failure of attempted airway Process Lewis SR., Butler AR., Parker J., Cook TM., Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. The Cochrane database of systematic reviews 2016; 11:CD011136. Medline
I Neutral (Yellow) First pass success Process Driver BE., Prekker ME., Moore JC., Schick AL., Reardon RF., Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Academic emergency medicine 2016; 23(4):433-9 Medline
I Neutral (Yellow) Overall intubation success Process Goksu E., Kilic T., Yildiz G., Unal A., Kartal M. Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED. Turkish journal of emergency medicine 2016; 16(2):53-56. Medline
I Neutral (Yellow) Survival to hospital discharge Patient ED-MD Yeatts DJ., Dutton RP., Hu PF., et al. Effect of video laryngoscopy on trauma patient survival: A randomized controlled trial. J Trauma Acute Care Surg 2013; 75(2):212-219. Medline
I Opposes (Red) Success Process Trimmel H., Kreutziger J., Fitzka R., Szüts S., Derdak C., Koch E., et al. Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial. Crit Care Med 2016; 44(7):e470-6. Medline
II Supportive (Green) Success Process OR Ayoub. Tracheal intubation following training with Glidescope vs direct laryngoscopy. Anaesthesia 2010; 65:674-8. Medline
II Supportive (Green) Laryngeal view Patient PH-MD & CCT Hossfeld B., Frey K., Doerges V., Lampl L., Helm M. Improvement in glottic visualisation by using the C-MAC PM video laryngoscope as a first-line device for out-of-hospital emergency tracheal intubation: An observational study. Eur J Anaesthesiol 2015; 32(6):425-31. Medline
II Supportive (Green) Multiple measures of chest compression interruptions Process Jarman AF., Hopkins CL., Hansen JN., Brown JR., Burk C., Youngquist ST. Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts. Prehosp Emerg Care 2017; 21(5):628-35. Medline
II Supportive (Green) First pass success Process Lee JK., Kang H., Choi HJ. Changes in the first-pass success rate with the GlideScope video laryngoscope and direct laryngoscope: a ten-year observational study in two academic emergency departments. Clinical and Experimental Emergency Medicine 2016; 3(4):213-218. Medline
II Supportive (Green) Successful tracheal intubation (with first device) Process ED-MD Michailidou M., O'Keeffe T., Mosier JM., et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg 2015; 39(3):782-8. Medline
II Supportive (Green) First-pass intubation success Process Savino PB., Reichelderfer S., Mercer MP., Wang RC., Sporer KA. Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis. Academic Emergency Medicine 2017; 24(8):1018-26. Medline
II Supportive (Green) Number of attempts to intubate Patient PH-Paramedic Wayne MA., McDonnell M. Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation. Prehosp Emerg Care 2010; 14(2):278-282. Medline
III Supportive (Green) Time to success Process Bahathiq AO., Abdelmontaleb TH., Newigy MK. Learning and performance of endotracheal intubation by paramedical students: Comparison of GlideScope(®) and intubating laryngeal mask airway with direct laryngoscopy in manikins. Indian J Anaesth 2016; 60(5):337-42. Medline
III Supportive (Green) Time to insertion Process Butchart AG., Tjen C., Garg A., Young P. Paramedic laryngoscopy in the simulated difficult airway: Comparison of the venner A.P. advance and GlideScope ranger video laryngoscopes. Acad Emerg Med 2011; 18(7):692-8. Medline
III Supportive (Green) Successful intubation Process SIM Cinar O., Cevik E., Yildirim AO., Yasar M., Kilic E., Comert B. Comparison of GlideScope video laryngoscope and intubating laryngeal mask airway with direct laryngoscopy for endotracheal intubation. Eur J Emerg Med 2011; 18(2):117-20. Medline
III Supportive (Green) First Pass Success Process Ducharme S., Kramer B., Gelbart D., Colleran C., Risavi B., Carlson JN. A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation 2017; 114:121-126. Medline
III Supportive (Green) Time to visualization of glottic opening Process Eismann H., Sieg L., Etti N., Friedrich L., Schröter C., Mommsen P., et al. Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins. Eur J Med Res 2017; 22(1):27. Medline
III Supportive (Green) Time to intubation Process Gawlowski P., Smereka J., Madziala M., Cohen B., Ruetzler K., Szarpak L. Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics: A randomized crossover manikin trial. Medicine 2017; 96(16):e5873. Medline
III Supportive (Green) Overall success rate Process SIM Kaplan A., Goksu E., Yildiz G., Kilic T. Comparison of the C-MAC videolaryngoscope and rigid fiberscope with direct laryngoscopy in easy and difficult airway scenarios: A manikin study. J Emerg Med. 2016;50(3):e107-14. Medline
III Supportive (Green) Agitation scale Patient In-Patient Kovacs G., et al. A Comparison on a fiberoptic stylet and a bougie as adjuncts to direct laryngoscopy in a manikin-simulated difficult airway. Ann Emerg Med 2007; 50:676-85. Medline
III Supportive (Green) Intubation success Process SIM Lewis AR., Hodzovic I., Whelan J., Wilkes AR., Bowler I., Whitfield R. A paramedic study comparing the use of the Airtraq, Airway Scope and Macintosh laryngoscopes in simulated prehospital airway scenarios. Anaesthesia 2010; 65(12):1187-93. Medline
III Supportive (Green) Intubation success Process SIM Liu L., Tanigawa K., Kusunoki S., Tamura T., Ota K., Yamaga S., et al. Tracheal intubation of a difficult airway using Airway Scope, Airtraq, and Macintosh laryngoscope: A comparative manikin study of inexperienced personnel. Anesth Analg 2010; 110(4):1049-55. Medline
III Supportive (Green) Intubation success Process SIM Nasim S., Maharaj CH., Malik MA., O'Donnell J., Higgins BD., Laffey JG. Comparison of the glidescope and pentax AWS laryngoscopes to the macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation. BMC Emerg Med 2009; 9:9-227X. Medline
III Supportive (Green) Intubation success Process OR Noppens RR. Evaluation of the McGrath Video laryngoscope after failed direct laryngoscope. Anaesthesia 2010; 65:716-20. Medline
III Supportive (Green) Endotracheal intubation (ETI) attempts, success rates Patient Thomas S., Judge T., Lowell MJ., et al. Airway management success and hypoxemia rates in air and ground critical care transport: A prospective multicenter study. Prehosp Emerg Care 2010; 14(3):283. Medline
III Supportive (Green) Success rate Process Yildirim A., Kiraz HA., Ağaoğlu, Akdur O. Comparison of Macintosh, McCoy and C-MAC D-Blade video laryngoscope intubation by prehospital emergency health workers: a simulation study. Intern Emerg Med 2017; 12(1):91-97. Medline
III Neutral (Yellow) Success rate Process SIM Amathieu R., Sudrial J., Abdi W., Luis D., Hahouache H., Combes X., et al. Simulating face-to-face tracheal intubation of a trapped patient: a randomized comparison of the LMA Fastrach™, the GlideScope™, and the Airtraq™ laryngoscope. Br J Anaesth 2012; 108(1):140-5. Medline
III Neutral (Yellow) First pass success rate Process Hafner JW., Perkins BW., Korosac JD., Bucher AK., Aldag JC., Cox KL. Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting. Air Med J 2016; 35(3):132-7. Medline
III Neutral (Yellow) Success rate of endotracheal intubation Process Kim JW., Park SO., Lee KR., Hong DY., Baek KJ., Lee YH., et al. Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Resuscitation 2016; 105:196-202. Medline
III Neutral (Yellow) Success rate Process Pieters BM., Wilbers NE., Huijzer M., Winkens B., van Zundert AA. Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel. Anaesthesia 2016; 71(5):556-64. Medline
III Neutral (Yellow) ETI success rate Patient OR Putz L., Dangelser G., Constant B., Jamart J., Collard E., Maes M., et al. Prospective trial comparing Airtraq and Glidescope techniques for intubation of obese patients. Ann Fr Anesth Reanim 2012; 31(5):421-6. Medline
III Neutral (Yellow) Time to intubation Process Truszewski Z., Czyzewski L., Smereka J., Krajewski P., Fudalej M., Madziala M., et al. Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes. Am J Emerg Med 2016; 34(9):1835-9. Medline
III Neutral (Yellow) Time to intubation Process Yousif S., Machan JT., Alaska Y., Suner S. Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment. Prehosp Disaster Med 2017; 32(4):352-356. Medline
III Neutral (Yellow) Time to successful ventilation Process SIM Yun BJ., Brown CA.,3rd, Grazioso CJ., Pozner CN., Raja AS. Comparison of video, optical, and direct laryngoscopy by experienced tactical paramedics. Prehosp Emerg Care 2014; 18(3):442-445. Medline
X Not Yet Graded (White) - Angerman S., Kirves H., Nurmi J. A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation. Anaesthesia 2018; 73(3):348-55. Medline
X Not Yet Graded (White) - Arulkumaran N., Lowe J., Ions R., Mendoza M., Bennett V., Dunser MW. Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth 2018; 120(4):712-24. Medline
X Not Yet Graded (White) - Bhattacharjee S., Maitra S., Baidya DK. A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials. J Clin Anesth 2018; 47:21-6. Medline
X Not Yet Graded (White) - Cavus E., Janssen S., Reifferscheid F., Caliebe A., Callies A., von der Heyden M., et al. Videolaryngoscopy for Physician-Based, Prehospital Emergency Intubation: A Prospective, Randomized, Multicenter Comparison of Different Blade Types Using A.P. Advance, C-MAC System, and KingVision. Anesth Analg 2018; 126(5):1565-74. Medline
X Not Yet Graded (White) - Jiang J., Ma D., Li B., Yue Y., Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Crit Care 2017; 21(1):288. Medline


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