Airway management remains a fundamental skill for all emergency physicians. Extraglottic airway devices (EGAs) have become a widely accepted means of airway management along with rescue airway devices. We aim to clarify the role of these devices in the prehospital setting and discuss considerations surrounding the most frequently used devices in current practice. Although we discuss the benefits of various commercial products, none of the authors endorse any individual device detailed below.

Historically, the endotracheal tube (ETT) has been considered the definitive airway of choice in both the prehospital and in-hospital setting. Emergency medical services (EMS) scope of practice is governed by the state, but national scope of practice guidelines are available for the four different EMS provider levels. The guidelines, updated most recently in 2019, note that endotracheal intubation is reserved for paramedics. Extraglottic devices, however, are in the scope of practice for both advanced emergency medical technicians (AEMTs) and paramedics, making the devices more widely applicable.¹ Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. With more recent studies such as the AIRWAYS-2 and PART trials showing no significant benefit to using ETTs over EGAs and even possible evidence of benefit with EGAs, the role of the prehospital ETT may be further restricted in the coming years.^2,3,4 With the current prehospital emphasis on EGAs, it is important for emergency physicians to understand which current extraglottic devices are commercially available and the role each plays in the management of the compromised airway in the prehospital setting.

Proposed benefits to EGAs include ease and speed of placement, reduced need for training, reduced need for sedation and paralytic medications to facilitate placement, and reduced risk of complications during the procedure.⁵ Due to these benefits, many protocols (both prehospital and hospital-based) list EGAs as a key step in both standard and failed airway management; however, potential risks come with using EGAs in lieu of ETTs. Because EGAs do not isolate the trachea as the ETT does, the risk of aspiration events increases, and due to the blind placement of many of these devices, unidentified airway occlusion can occur.⁶ Additionally, EGAs are not generally considered to be “definitive” airways and are typically exchanged for an ETT at patient hospital presentation, although they can be used with mechanical ventilation for up to 24 hours.⁷

Laryngeal Mask Airway (LMA)

Developed in the 1980s and first introduced into the prehospital setting in 1992, the LMA spearheaded the broader introduction of extraglottic devices into prehospital practice.⁸ Initially developed as a surgical adjunct, the LMA proved to be easily adaptable to the less controlled environments of the prehospital setting.⁹ LMAs use an inflatable mask expanded using a similar technique to the endotracheal tube cuff. LMAs are intended to cover the laryngeal inlet, thus isolating the airway from the esophagus. These devices are currently manufactured by several companies and have multiple variants, including the LMA Supreme (manufactured by The Laryngeal Mask Company Ltd) and the LMA-Proseal and LMA-Fastrach (manufactured by LMA North America), which aim to improve certain aspects of the LMA device, such as ease of placement or improved isolation of the respiratory tract.⁶ Because LMAs require inflation to function appropriately, they are at risk of balloon rupture or loss of seal pressure. While not unique to LMAs, the potential risk of airway occlusion is higher than it is for other EGAs.⁷