A Meta-Analysis of Prehospital Airway Control Techniques Part I: Orotracheal and Nasotracheal Intubation Success Rates

Abstract Background. Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. Objective. We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. Methods. We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. Results. Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%–89.4%); OETI for non–cardiac arrest patients: 69.8% (50.9%–83.8%); DFI 86.8% (80.2%–91.4%); and RSI 96.7% (94.7%–98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%–95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%–83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. Conclusions. We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure.