The i‐gel^® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID‐19 pandemic

Abstract

ObjectiveUnlike randomized controlled trials, practical real‐world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID‐19 pandemic‐driven shift from endotracheal intubation (ETI) to the i‐gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first‐pass success and timing to successful airway placement between ETI and the i‐gel® SGA under extenuating circumstances.MethodsThis pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non‐trauma‐related conditions. Data from EMS records were extracted over 2 years, 12 months pre‐pandemic, and 12 months post‐pandemic. During the pre‐COVID‐19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post‐pandemic paramedics were mandated to utilize i‐gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group).ResultsThere were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First‐pass success was significantly higher with SGA 96% (92%–99%) than ETI 68% (57%–78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first‐pass success was significantly shorter in the SGA group (5.9 min [5.1–6.7 min]) than in the ETI group (8.3 min [6.9–9.6 min]), as was time to overall successful placement at 6.0 min (5.1–6.8 min) versus 9.6 min (8.2–11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator‐free days between the groups were not statistically different between the groups.ConclusionIn this natural experiment, the SGA performed significantly better than ETI in first‐pass airway device placement success and was significantly faster in achieving first‐pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real‐world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.