Airway Management Under Pressure: How Different Devices Stack Up in Prehospital Care
"A comparative look at E.T. Tubes, LMA Classics, and S.A.L.T. devices in simulated prehospital settings reveals key insights for emergency medical technicians."
In emergency medicine, ensuring a patient has a clear and secure airway is paramount, especially in the chaotic environment of prehospital care. Proper airway maintenance and respiratory support can significantly impact a patient's chances of survival and positive outcomes. Emergency Medical Technicians (EMTs) rely on established guidelines that designate the legal scope of practice for airway management, including endotracheal and laryngeal mask intubation.
However, the reality on the ground often differs from established protocols. Data reveals a surprisingly low rate of endotracheal intubation in prehospital settings. This discrepancy highlights the challenges EMTs face when performing advanced airway procedures in the back of a moving ambulance.
To address this gap between guidelines and practice, researchers are constantly exploring and refining airway devices and techniques. This article delves into a simulation study that compares the effectiveness of three common airway devices—Endotracheal Tubes (E.T. tubes), Laryngeal Mask Airway (LMA-Classic), and Supra-glottic Airway Laryngopharyngeal Tubes (SALT)—in both controlled indoor and challenging ambulance settings. By understanding the strengths and weaknesses of each device, EMTs can make informed decisions to optimize patient care during those critical first moments.
Current Airway Management Data
A multicenter retrospective chart review examined 11,475 intubations performed in 15 community emergency departments between January 1, 2015, and December 31, 2022. The review recorded patient characteristics, rapid sequence intubation medications, cricoid-pressure use, intubation method, number of attempts, admission diagnosis, and all-cause mortality. Active cardiopulmonary resuscitation occurred in 11.4% of intubations. Separately, a tertiary-care facility retrospectively analyzed 340,748 airway-management procedures over 16 years.
From Guidelines to Advanced Devices
Modern airway management has developed through dedicated professional bodies, organized training, evidence-based guidelines and algorithms, multicenter studies, international databases, audits, textbooks, and specialist journals. In the last 25 years, videolaryngoscopes and supraglottic airways have entered routine use among new anesthesia trainees. The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society, published in 2011, was described as a seminal report that influenced airway practice. Coordinated airway planning, consensus guidelines, and difficult-intubation trolleys are identified as modern developments focused largely on managing the difficult airway.
E.T. Tube vs. LMA Classic vs. S.A.L.T.: Which Airway Device Reigns Supreme?
A recent study aimed to shed light on the practical differences between these devices by comparing intubation success rates and the time required to secure an airway. The researchers used mannequins in two scenarios: a controlled indoor setting and a simulated ambulance environment.
- Participants: The study included 60 participants, primarily emergency rescue major students.
- Devices Compared: Endotracheal Tube (E.T. tube), Laryngeal Mask Airway (LMA-Classic), and Supra-glottic Airway Laryngopharyngeal Tube (SALT).
- Scenarios: Indoor setting and simulated ambulance environment.
- Measurements: Intubation success rate and time to secure the airway.
AI, Robotics, and Acute-Care Reviews
Recent airway research includes medical robotics and artificial intelligence for tracheal intubation and anatomical-structure recognition. A 2025 narrative review describes current capabilities in robotic and AI-assisted tracheal intubation while noting that many healthcare professionals still find these technologies unfamiliar and complex. A separate review of adult airway management in acute care examines assessment, preparation, pharmacological considerations, intubation techniques, rescue options, confirmatory testing, and post-sedation and ventilator management. Together, these sources show a field combining emerging technology reviews with broad assessments of contemporary acute-care practice.
Limits of a Three-Device Simulation
A simulation study of prehospital airway management used mannequins to compare three devices: an endotracheal tube, the classic laryngeal mask airway, and the SALT device. The source presents the work as a comparative experiment limited to those three airway devices. It specifically proposes that future studies include a wider range of airway devices and other comparisons. This limitation means the study should not be treated as a comprehensive assessment of all prehospital airway options.
Training and Device Comparisons
One study comparing traditional and online airway-management education reported statistically significant differences in mean time to successful intubation at non-difficult, moderately difficult, and difficult airway levels, with p values of 0.005, 0.007, and 0.014, respectively. In an earlier prospective review, 178 endotracheal intubations by paramedics were examined over nine months; 149 patients, or 83.7%, had medical conditions, while 29, or 16.2%, had trauma. Another study randomly allocated 72 paramedics to intubate an adult manikin after education on endotracheal intubation, the laryngeal mask airway, and the I-gel. These studies compare training formats, describe a paramedic intubation cohort, and evaluate device use in a mannequin setting, but their snippets do not establish a single overall winner among devices.
Making Informed Choices for Airway Management
This simulation study provides valuable insights into the practical application of different airway devices in prehospital settings. While the LMA-Classic emerged as the preferred choice in this study, the ideal device may vary depending on the specific circumstances and the EMT's experience. Further research, including studies with a wider range of devices and real-world patient scenarios, will continue to refine our understanding of optimal airway management strategies in emergency medicine.
Consensus and Collective Expertise
Expert commentary emphasizes structured approaches to airway management and the use of collective professional judgment. One source proposes using a Delphi method to obtain expert-panel advice in clinical practice or malpractice cases, with the goal of improving global airway management practice. During the COVID-19 pandemic, an international expert panel formulated consensus opinions on controversial topics in advanced airway management using the available literature. More recent reviews continue to organize decision-making around assessment, preparation, intubation, rescue options, confirmation, and post-sedation and ventilator management.
People, Physiology, and Visibility
Airway management, including tracheal intubation and tracheostomy, is described as the most commonly performed procedure in critically ill patients. Intensive-care airway management can be anatomically and physiologically challenging and carries potential for peri-intubation adverse events. A case report cited in a difficult-airway review describes ketamine-induced spontaneous-breathing intubation with airway topicalization in a retrieval-care case involving airway obstruction. Another real-world account argues that traditional or tactile-only insertion, and some camera-assisted systems with the visual aid at the endotracheal-tube tip, can limit manoeuvrability and provide suboptimal views of the tracheal pathway.