Discussion

Guidelines for the initial emergent airway management of patients in respiratory failure were modified to some extent for nearly all emergency providers, including EMS personnel, during the COVID-19 pandemic. ^{Reference Hart, Tracy and Johnston1} These guideline modifications differed from one hospital system to another and frequently changed throughout the course of the pandemic as public health officials learned more about the pathophysiology of viral infection and principles of its transmissibility. In general, guidelines recommended the utilization of rapid sequence intubation (RSI) technique utilizing VL to intubate patients, when necessary, with minimal use of bag valve mask (BVM) technique to decrease the risk of aerosolizing virus particles. ^{Reference Meng, Qiu and Wan2–Reference Cheung, Ho and Cheng4} Similarly, placement of a surgical mask over any nasal cannula and/or face mask utilized for apneic oxygenation was recommended. ^{Reference Brewster, Chrimes and Do3,Reference Gleason, Christian and Barton5,Reference Sliva, Cabrera and Barrionuevo6}

Just as the management of in-hospital airway decompensation changed during the height of the pandemic, EMS agencies also modified their protocols to decrease the risk of airborne exposure to the virus. Certain guidelines recommended that first responders with access to VL should engage in one attempt at endotracheal RSI, followed by SGA insertion with a second-generation device if initial endotracheal attempt was unsuccessful. To decrease the risk of repeated and unnecessary exposures to respiratory droplets, guidelines also recommended against both the use of direct laryngoscopy (DL) and repeated attempts at TI. If providers did not have access to VL and/or RSI, second generation SGAs were favored as a preferred initial airway management method; first generation SGA devices have been shown to have an inferior seal when compared to their ETT counterparts. ^{Reference Cheung, Ho and Cheng4,Reference Henlin, Sotak and Kovaricek7–Reference Bercker, Schmidbauer and Volk9} Unfortunately, Basic Life Support (BLS) crews practicing in areas that do not permit SGA placement within their scope of practice had to utilize BVM ventilation with a tight seal and a high-efficiency particulate air (HEPA) filter while wearing appropriate personal protective equipment (PPE). ^{Reference Edelson, Sasson and Chan10}

Interestingly, the American College of Emergency Physicians’ (ACEP; Irving, Texas USA) Air Method Guidelines for prehospital providers taking care of patients with suspected or confirmed COVID-19 illness do not suggest a preferred initial airway management method. In fact, the guidelines encouraged providers to consider the decreased airborne transmission risk of TI compared to NIPPV, particularly in COVID+ patients with a high risk of respiratory decline who would be likely to require TI regardless of any NIPPV trial. They did not, however, mention or address the use of RSI or VL in comparison to DL. ¹¹

While local ALS providers do have access to VL, it had only recently been implemented at the start of the pandemic and therefore the agency recommended SGA placement as its preferred initial airway management device. Several other institutions implemented similar guidelines paralleling this recommendation, including the Maryland Institute for Emergency Medical Systems (MIEMS; Baltimore, Maryland USA), which advised the use of SGAs rather than traditional TI methods to all its EMS providers and clinicians. ¹²

Though past studies have demonstrated that successful prehospital TI is associated with improved outcomes over SGA insertion, the Agency for Healthcare Research and Quality’s (AHRQ; Rockville, Maryland USA) recent systematic review of prehospital airway management data found no difference in primary patient outcome when comparing different prehospital airway management techniques across all emergency types and age groups. ^{Reference Wang, Szydlo and Stouffer13,Reference Carney, Cheney and Totten14} In adult and pediatric patients with cardiac arrest and adult patients with mixed emergency types, however, outcomes did favor SGA placement when comparing first-pass success rates of SGAs and ETTs. ^{Reference Carney, Cheney and Totten14}

It is clear from this study that providers, even after the height of the COVID-19 pandemic, were more successful on their first attempt when placing an SGA compared to an ETT. The protocol change, prioritizing SGA placement over RSI/TI, likely contributed to the observed decrease in intubation success rates, as the lack of practice with the procedure in 2020 could have impacted provider proficiency over time. This local agency did not implement specific simulation or training sessions during the pandemic to offset this decline, which may have further affected success rates. These findings underscore an important opportunity to enhance prehospital providers’ psychomotor skill development, especially when protocol changes limit hands-on experience. Although the direct translation of simulated to real-time procedural competence remains uncertain, studies support the value of high-quality simulation in teaching and assessing skills that are infrequently performed in the field. ^{Reference Tavares, LeBlanc, Mausz, Sun and Eva15–Reference Albert and Training18}

Research underscores the importance of skill retention and the impact of training frequency on intubation success rates for prehospital providers. Studies, such as Carney, et al’s systematic review, indicate that SGAs generally yield higher first-pass success rates compared to TI in prehospital settings, suggesting that SGAs may serve as a more reliable option when provider exposure to ETI is limited. ^{Reference Carney, Totten and Cheney19} Similarly, Abelsson, et al highlight the critical role simulation plays in maintaining competence for complex, high-stakes procedures like intubation, which are infrequently performed in real-world settings. ^{Reference Abelsson, Rystedt, Suserud and Lindwall20} Without simulation or consistent hands-on training, prehospital providers may experience skill decay, impacting success rates during emergent airway management. Additionally, foundational work by Pepe, et al emphasizes that, while TI offers definitive airway control, it requires substantial initial training and periodic refreshers to maintain proficiency – resources that were challenging to provide during the COVID-19 pandemic. ^{Reference Pepe, Copass and Joyce21} These insights collectively support the need for regular simulation-based training or alternative approaches, such as prioritizing SGA placement, to enhance provider readiness and mitigate the impact of procedural infrequency on patient outcomes.

From a management standpoint, awareness of staff procedure success rates is also crucial for agency leaders to identify areas of improvement and plan continuing education opportunities that address areas of weakness across agency providers. Transparency with providers regarding the results of these studies is also important, not only to their understanding of their skill development and growth as providers and teachers in the field, but also to their clinical practice. Based on feedback, one may elect to seek further agency- or local-based opportunities for improvement, or reconsider whether the benefit of proceeding with an infrequently practiced procedure outweighs the risks if unsuccessful. Further studies are required to determine the most appropriate clinical scenarios for providers to utilize SGA placement or RSI/endotracheal intubation as their first-line advanced airway management strategy, and to identify the best approach to remediation or education regarding any identified psychomotor skill deficiencies.