Secular Trends in Airway Management of Out-of-Hospital Cardiac Arrest in the National EMS Information System (NEMSIS) Dataset

Introduction Advanced airway management is essential in resuscitation from out-of-hospital cardiac arrest (OHCA). No longitudinal national studies have described longitudinal trends in airway device choice. We sought to evaluate secular trends of OHCA endotracheal intubation (ETI) and supraglottic airway (SGA) in the United States (US). Methods We evaluated ETI and SGA use for 2013-2022 in adult OHCA in the US using the National EMS Information System (NEMSIS) database. We identified OHCA events (CPR performed or defibrillation) and evaluated the proportions of ETI and SGA used during OHCA. We repeated the results stratified by urbanicity. We used descriptive statistics to describe incidence prevalence with nonparametric trend testing for proportional changes over time and a two-sample stochastic rank sum test for equivalence to evaluate airway use differences by urbanicity. Results During the study period, we observed 320,154,097 adult 9-1-1 events. Of 3,118,703 OHCA, there were 699,568 and 337,458 cases with reported ETI and SGA attempts. The dominant airway choice was ETI, though the trend of ETI choice decreased as SGA increased over time (p-trend <0.05). From 2013 to 2022, SGA use increased in urban settings while rural and suburban remained stable (urban 27% to 39%*; suburban 31% to 29%; rural 28% to 29%, respectively, *p<0.05). Conclusion Over ten years, rates of advanced airway use have increased, with ETI remaining the predominant airway for adults in OHCA. Interestingly, ETI choice decreased as SGA increased over the study period. SGA use distinctly differed in urban settings, increasing concerns for disparities in care provision among communities. With the increased use of SGA over time, further evaluation of patient outcomes is required in datasets with robust linkage to Utstein variables. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial N/A ### Funding Statement No funding was used for this study. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The American Institutes of Research Institutional Review Board approved the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable All data in the manuscript is public access from the National EMS Information System (NEMSIS). * ### Abbreviations CPR : cardiopulmonary resuscitation BVM : bag valve mask EMS : emergency medical services ETI : endotracheal intubation ICD : International Classification of Diseases IRB : international research board NEMSIS : National Emergency Medical Services Information System OHCA : out of hospital cardiac arrest ROSC : return of spontaneous circulation SGA : supraglottic airway SNOMED : systematized nomenclature of medicine