Other studies validated this suggestion with mixed outcomes. The PART trial, a well conducted, pragmatic, cluster-crossover trial from 2018 evaluated outcomes of 3,000 out-of-hospital cardiac arrest (OHCA) patients in the United States. Approximately half of OHCA patients were randomly assigned to ETI, and half received a supraglottic laryngeal tube (King LT, often called King airways) as the intervention. Survival after 72 hours was 18.3 percent in the LT group compared with 15.4 percent in the ETI group, a statistically significant difference. Notably, however, the first airway attempt after EMS arrival in the LT group was 2.7 minutes shorter than with the ETI group. It is therefore possible that in this study, the timing mattered more than the specific intervention. Unsuccessful insertion for the ETI group was 44.1 percent compared with 11.8 percent in the LT group. Finally, it should be noted that EMS’s LTs were converted to ETI at the receiving emergency department 64.4 percent of the time.²

The AIRWAYS-2 trial was a massive cluster randomized controlled trial from the United Kingdom that evaluated 30-day good functional outcomes in OHCA survivors. The clusters were assigned to a specific type of SGA (iGel) versus ETI. The dataset was large enough to include 9,296 patients; no difference was found between the two groups. Although the study had limitations, it appears that it would be fair to conclude from AIRWAYS-2 that iGels are noninferior in the prehospital setting to ETI and vice-versa. Therefore, from this single study, we would be willing to challenge the “gold standard” idea when it comes to OHCA and paramedics. Subsequent three-month and six-month follow-up seems to corroborate the initial data of AIRWAYS-2, with the caveat that a very low percentage of patients responded to request for follow up.^3,4

Which is Best?

In an official position statement, the National Association of EMS Physicians (NAEMSP) favors the use of prehospital SGAs: “SGAs have utility as a primary or secondary EMS airway intervention.”

EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.

In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.

Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.⁵

If SGAs are as efficacious and safe as ETI, the question arises as to which type of SGA is the best. Several different styles are commercially available. A comparison between the King-LT and iGel was attempted in OHCA situations and, overall, the outcomes were not hugely different. There were some nuanced differences. Survival to discharge home was approximately the same between the two groups when the SGA was the primary airway device; but when the SGA was used as a rescue device for failed intubation, the iGel did better. The authors therefore concluded that the iGel for adult OHCA resuscitation had better outcomes as compared with the King-LT.⁶ It may be reasonable, as a conclusion, to keep it simple: Both devices are good, so one might choose the easiest one to use. The iGel does not have a cuff, meaning no syringe is required for insertion and it really has no failing parts.