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By Orlando E. Rivera, DNP, MBA, RN
Abstract
Prehospital airway management has become more than a clinical procedure; it’s become a symbol. But when the tube becomes a trophy, patients pay the price. A growing body of evidence from 2024 and 2025 challenges the status quo, urging EMS to recalibrate its airway priorities.
This article dives into the latest research on supraglottic devices, endotracheal intubation (ETI), and outcomes in cardiac arrest and trauma, and asks: are we intubating to save lives or to validate our skillset?
The Patch and the Pipe
There’s a silent competition in EMS. Not spoken out loud, but felt in the back of every medic’s mind: Who got the tube? We celebrate it like a notch in the belt. We remember our first successful ETI like a rite of passage.
But what if we’ve built a culture where the tube has become a statement instead of a solution? The airway is a tool not a trophy. And it’s time we treated it that way.
ETI: A Tradition Under Fire
New evidence paints a complicated picture of prehospital endotracheal intubation. A major U.S. study found SGA use surpassed ETI in cardiac arrest, with no decline in outcomes and gains in speed and ease of placement.1
SGA devices like the i-gel® show an 88% success rate in real-world field use2 Many systems now replace ETI with SGA after ROSC, as patient ventilation and survival are not compromised.3
When Skill Become Symbol
ETI has historically been the gold standard, partly because of its difficulty. That difficulty became a proxy for competence.
But as evidence-based medicine evolves, the question becomes whether we’re intubating because it benefits the patient or because it validates our role. This question becomes especially critical in pediatric and trauma cases.
Pediatric Trauma: Less Might Be More
A 2025 study comparing basic vs. advanced airway procedures in pediatric trauma found basic management was as effective, sometimes superior, particularly due to its speed and fewer complications.4
Too often, pediatric intubation is attempted more out of pressure to “do something” than from solid clinical justification.
But failed attempts, prolonged apnea times, and misplaced tubes cause more harm than good, especially in smaller airways where seconds count. Just because we can intubate doesn’t mean we should. In kids, less may not just be more, it may be life-saving.
Traumatic Cardiac Arrest: Who Really Benefits?
A Japanese study in 2025 found improved neurological outcomes from prehospital intubation in a specific subset of trauma patients: under 65 years old, with chest injuries, and long transport times.4
For other groups, no survival benefit was found.
Our Protocols Aren’t Keeping Up
Despite over 630,000 records analyzed in the new national guidelines,5 EMS systems still default to ETI. Only 21% of guidelines meet National Academy of Medicine quality standards.6
The 2024 NEMSQA report urges adoption of quality metrics like first-pass success and waveform capnography.7
A Culture Shift, Not a Skill Dump
This isn’t about eliminating ETI, it’s about using it judiciously. Changing airway culture means asking: would SGA be safer right now?
Does this patient benefit from ETI? Am I intubating for the patch or for the patient?
Airway Humility Is Airway Excellence
We teach providers to assess the airway. Now we must teach them to assess their intentions.
In a new era of data-driven EMS, success isn’t defined by the most difficult procedure, it’s defined by the most appropriate one. The next time you reach for the tube, ask yourself: Am I here to impress or to save?
And to the paramedic programs still treating intubation as the crown jewel of airway care: teach your students that mastery isn’t just about performing the hardest skill, it’s knowing when not to.
Today’s airway excellence means understanding that less is sometimes more. Especially when your patient is small, scared, or silently slipping away.
About the Author
Dr. Orlando E. Rivera is a distinguished figure in healthcare, with over three decades of comprehensive experience. Holding a Doctorate in Nursing Practice and an MBA with a healthcare focus, Dr. Rivera’s proficiency encompasses emergency and prehospital medicine, cardiology, cardiovascular quality, air medical services and critical care. His executive leadership roles further attest to his vast knowledge and skill in these domains. Renowned for his positive demeanor and dedication to continuous learning, Dr. Rivera exemplifies the ideals of professionalism and innovation in healthcare, making significant strides in advancing medical practices and patient care standards. His journey in healthcare reflects a relentless pursuit of excellence and a deep commitment to improving the lives of those in need.
References
1. Wang HE, Yu MI, Crowe RP, et al. Longitudinal Changes in Emergency Medical Services Advanced Airway Management. JAMA Netw Open. 2024;7(8):e2427763. doi:10.1001/jamanetworkopen.2024.27763
2. Handtevy. (2025). Paramedic i-gel® placement and perception of use in prehospital airway management. https://www.handtevy.com/wp-content/uploads/2025/04/Paramedic-i-gel-Placement-and-Perception-of-Use-in-Prehospital-Airway-Management-1.pdf
3. Winniford, C. EMS Airway. (2024). Operational realities of evidence-based medicine in prehospital airway management. https://emsairway.com/2024/07/15/operational-realities-of-evidence-based-medicine-in-prehospital-airway-management/
4. International Prehospital Medicine Institute. (2025). Literature Review – May 2025. https://www.jems.com/patient-care/international-prehospital-medicine-institute-literature-review-may-2025/
5. USFA. (2024). New evidence-based guidelines for prehospital airway management. https://www.usfa.fema.gov/blog/new-guidelines-for-prehospital-airway-management/
6. Martin-Gill, C., Patterson, P. D., Richards, C. T., Misra, A. J., Potts, B. T., & Cash, R. E. (2025). 2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care. Prehospital Emergency Care, 29(6), 703–712. https://doi.org/10.1080/10903127.2024.2412299
7. NEMSQA. (2024). Measures Report: Airway Management. https://www.nemsqa.org/assets/Airway/2024%20NEMSQA%20Measures%20Report%20Airway%20Management.pdf
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