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Original Investigation | Emergency Medicine
Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes
Michelle M. J. Nassal, MD, PhD; Betty Y. Yang, MD; Jane Hall, PhD; Jenny Shin, MPH; Christopher B. Gage, MHS, NRP; Jonathan R. Powell, PhD; Ashish R. Panchal, MD, PhD;
Andrew J. Latimer, MD; Henry E. Wang, MD, MS; Thomas D. Rea, MD, MPH; Nicholas J. Johnson, MD
Abstract
IMPORTANCE Although advanced airway (AA) practice patterns have varied over time, their
association with out-of-hospital cardiac arrest (OHCA) outcomes is unknown.
OBJECTIVE To determine the association between AA temporal practice patterns of emergency
medical service (EMS) agencies and OHCA outcomes.
DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from multicenter EMS
agencies participating in the Cardiac Arrest Registry to Enhance Survival database. The study
included adults (aged �18 years) with OHCA treated by EMS agencies that had 25 or more OHCA
episodes annually from January 1, 2016, through December 31, 2022.
EXPOSURE AA interventions included supraglottic airway (SGA) device use or endotracheal
intubation (ETI). Patients were categorized into groups using the following EMS agency-level
patterns defined by predominant AA use before and after 2019: (1) ongoing ETI, (2) ongoing SGA use
(ongoing SGA), (3) transitioning from ETI to SGA use (ETI to SGA), or (4) transitioning from SGA use
to ETI (SGA to ETI).
MAIN OUTCOMES AND MEASURES Mixed-effects logistic regression models accounting for EMS
agency clustering and adjusting for Utstein variables were used to evaluate the association between
EMS agency AA practice patterns and OHCA outcomes including return of spontaneous circulation
(ROSC) and survival. Subanalyses were also conducted for agencies in the lowest survival quartile.
Odds ratios (ORs) are reported with 95% CIs.
RESULTS This study included 350 216 patients with OHCA treated by 254 eligible EMS agencies. The
214 EMS agencies (n = 305 341 patients) with a predominant AA pattern were grouped as follows for
temporal pattern analysis: ongoing ETI (n = 72 [33.6%]), ongoing SGA (n = 66 [30.8%]), ETI to SGA
(n = 67 [31.3%]), or SGA to ETI (n = 9 [4.2%]). Patients were predominantly male (62.2%), with a
median age of 64 (IQR, 52-76) years, and most (81.7%) presented with nonshockable rhythms. ROSC
occurred in 30.8% of patients, and 10.4% of patients survived to hospital discharge. Predominant
SGA use among EMS agencies increased from 65 agencies in 2016 to 113 in 2022. ROSC decreased in
all 4 groups from before to after 2019 as follows: from 36.5% to 30.7% (OR, 0.80 [95% CI,
0.77-0.82]) for ongoing ETI, from 32.4% to 26.4% (OR, 0.75 [95% CI, 0.73-0.78]) for ongoing SGA,
from 32.1% to 28.5% (OR, 0.88 [95% CI, 0.85-0.91]) for ETI to SGA, and from 36.7% to 33.3% (OR,
0.92 [95% CI, 0.83-1.03]) for SGA to ETI. For the 15 lower-performing agencies (n = 20 860 patients)
that transitioned from ETI to SGA after vs before 2019, an association with higher ROSC (from 25.7%
to 29.1%; OR, 1.16 [95% CI, 1.09-1.24]) and survival (from 5.6% to 6.3%; OR, 1.17 [95% CI, 1.04-1.32])
was observed.
(continued)
Key Points
Question Is there an association
between advanced airway practice
patterns and out-of-hospital cardiac
arrest (OHCA) outcomes?
Findings In this cross-sectional study of
350 216 patients with OHCA treated by
254 emergency medical service (EMS)
agencies, supraglottic airway (SGA)
device use increased from 2016 through
2022. In EMS agencies with low survival
rates before 2019, switching from
endotracheal intubation to SGA device
use was associated with improved
outcomes.
Meaning These findings suggest that
SGA device use by EMS agencies with
lower survival rates may be associated
with improved outcomes in patients
with OHCA.
+ Invited Commentary
+ Supplemental content
Author affiliations and article information are
listed at the end of this article.
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2025;8(9):e2532334. doi:10.1001/jamanetworkopen.2025.32334 (Reprinted) September 17, 2025 1/10
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Abstract (continued)
CONCLUSIONS AND RELEVANCE In this cohort study, SGA use among EMS agencies increased
over time. Although ROSC declined for all AA temporal practice patterns, the transition from ETI to
SGA use at EMS agencies with lower baseline survival was associated with improved outcomes.
Future studies are warranted to confirm these findings and to evaluate whether the observed
associations are consistent across diverse populations.
JAMA Network Open. 2025;8(9):e2532334. doi:10.1001/jamanetworkopen.2025.32334
Introduction
Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality globally.1 Current
American Heart Association guidelines recommend advanced airway (AA) placement during OHCA
resuscitation to facilitate effective ventilation and improved outcomes.2 Prehospital AA
management generally includes supraglottic airway (SGA) device placement or endotracheal
intubation (ETI). Several factors can influence AA practice patterns, such as paramedic skill set,
patient-related factors, and regional protocols or state laws. These factors have been associated with
variability in AA practice patterns of emergency medical service (EMS) agencies across the US.3
Moreover, AA practice patterns have evolved.4,5 Initially, SGA devices were used primarily as
rescue devices after failed ETI attempts.6 However, EMS agencies have increasingly adopted SGA
devices as the first-line airway strategy in patients with OHCA. This transition may have been
influenced by 2 large randomized clinical trials (PART and AIRWAYS-2) published in 2018 comparing
SGA devices with ETI in patients with OHCA7,8 or by practice changes related to the COVID-19
pandemic.9
Despite the aforementioned changes, it remains unclear whether changes in AA practice
patterns of EMS agencies affect outcomes following cardiac arrest. We sought to evaluate the
temporal patterns of EMS agency AA use and determine their association with OHCA outcomes in
the Cardiac Arrest Registry to Enhance Survival (CARES) network, the largest OHCA registry in
the US.
Methods
This cross-sectional study was approved by The Ohio State University Office of Responsible Research
Practices as nonhuman participant research; therefore, it was exempt from institutional review board
review, and the need for informed consent was waived. The study followed the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Design, Setting, and Participants
We performed a retrospective analysis using data from the CARES national database, which is a
national registry of OHCA events managed by Emory University and the Centers for Disease Control
and Prevention in Atlanta, Georgia. The CARES database includes data from more than 2300 EMS
agencies in 46 US states, and it collects data through 3 sources: 911 dispatch centers, EMS clinicians,
and receiving hospitals. Predefined required data elements describing OHCA characteristics,
interventions, and outcomes are recorded in a web-based registry. Optional data elements, including
prehospital AA use and attempts, may also be entered by individual EMS agencies. The full CARES
data dictionary of required and optional data elements is available and was last updated in 2023.10
Race and ethnicity was determined by EMS agency records. These data were included because race is
a known predictor in OHCA,11 and they are reported here as Black or African American, White, or
other race or ethnicity (which includes American Indian or Alaska Native, Asian, Hispanic or Latino,
Native Hawaiian or Other Pacific Islander, multiple races or ethnicities, or unknown race or ethnicity).
JAMA Network Open | Emergency Medicine Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes
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The CARES database12 requires that participants achieve more than 99% data entry completeness
and accuracy of required data elements to be included in the dataset.
We included all adults (�18 years) with nontraumatic OHCA reported from January 1, 2016,
through December 31, 2022. The CARES database only includes OHCA with documented
resuscitation efforts (defined as EMS-performed cardiopulmonary resuscitation [CPR], any
defibrillation, or both), including bystander-performed automated external defibrillator use.13,14 We
limited analysis to EMS agencies that reported 25 or more OHCA resuscitations annually and
answered 70% or more of AA optional data entries in the CARES database annually over this
time period.
Measures
AA interventions included ETI or SGA device use. SGA devices included the following, as entered by
EMS agencies: i-gel (Intersurgical Ltd), King laryngeal tube (Ambu), Combitube esophageal-tracheal
double lumen tube (Medtronic), Air-Q intubating laryngeal airway (AirLife), LMA (laryngeal mask
airway), other SGA, or other SAD (supraglottic airway device).
We first evaluated whether there were EMS agency-level AA practice pattern changes over our
cohort timespan. We used a random 10% sample of all eligible EMS agencies to determine the year
with the most agency practice change. We identified 2019 as the inflection point in AA practice
patterns (eFigure in Supplement 1). We set 2019 as the time point to compare pre and post EMS
agency practice patterns. Excluding 2019 OHCAs, we subsequently classified EMS agencies into 4
groups based on their predominant airway practice pattern (>55%) before and after 2019: (1)
predominant ETI use (ongoing ETI), (2) predominant SGA use (ongoing SGA), (3) transition from ETI
to predominantly SGA (ETI to SGA), and (4) transition from SGA to predominantly ETI (SGA to ETI).
We excluded EMS agencies that did not exhibit a predominant airway strategy (those with 1:1 SGA:ETI
use) over this study period.
Outcomes
The primary outcome of interest was return of spontaneous circulation (ROSC), because this is the
primary outcome of interest for EMS agencies and is the outcome most temporally linked to the
intervention. Secondary outcomes included survival to hospital discharge and survival with good
neurologic recovery, which are often influenced by other aspects of care, including hospital and
prognostication factors. Survival with good neurologic recovery was defined by the dichotomized
Cerebral Performance Category (CPC) scale, in which a CPC score of 1 or 2 was classified as good
neurologic recovery.15
Statistical Analysis
We used the Cochran-Armitage test for trend to evaluate the number of EMS agencies using SGA as
their predominant AA strategy over the time. To evaluate the association between EMS agency AA
patterns and outcomes, we used mixed-effects logistic regression models, treating EMS agency as a
random effect. Fixed effects included adjustments for Utstein variables, including age, sex, public
location, race and ethnicity, witnessed status, initial rhythm, and bystander CPR.16 We evaluated
model performance and selection using clinical judgment based on well-established OHCA variables
and the Akaike information criterion.16,17 We report random effects in accountability by percentages
with 95% CIs. AA practice patterns of EMS agencies before and after 2019 were treated as
independent variables, then linearly combined to account for time (reference group: pre-2019
ETI).18,19 To evaluate AA practice changes in lower-performing agencies, we separately examined the
subset of EMS agencies with the lowest pre-2019 survival quartile. Only patients with complete data
were included in the mixed-effects logistic regression models. Significance levels were evaluated
using 2-sided tests set at Pof each emergency medical services
(EMS) agency before and after 2019 was categorized
into 1 of 4 observed practice patterns: ongoing
endotracheal intubation (ETI), ongoing supraglottic
airway (SGA) device use, transition from ETI to SGA
use (ETI to SGA), or transition from SGA use to ETI
(SGA to ETI).
JAMA Network Open | Emergency Medicine Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes
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good neurologic recovery in the post-2019 period compared with the pre-2019 period (Table 2). In
contrast, a transition from ETI to SGA was not associated with lower odds of survival to hospital
discharge or survival with good neurologic recovery after 2019 (Table 2).
Figure 2. Predominant Advanced Airway (AA) Practice Patterns of Emergency Medical Service (EMS) Agencies, 2016-2022
250
200
150
100
50
0
100
80
60
40
20
90
70
50
30
10
0
N
o.
 o
f E
M
S 
ag
en
ci
es
 u
si
ng
 A
A 
de
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ce
s
SGA device use vs ETIA
SGA
ETI
2016 2017 2018 2019 2020 2021 2022
Year
SG
A 
us
e,
 %
Practice patternsB
2016 2017 2018 2019 2020 2021 2022
Year
Ongoing ETI
Ongoing SGA device use
ETI to SGA transition
SGA to ETI transition
(A) The majority of EMS agencies used endotracheal intubation (ETI) as their
predominant AA strategy during out-of-hospital cardiac arrest in 2016. Supraglottic
airway (SGA) device use became predominant among EMS agencies over time (P for
trend = .048). (B) Line graphs show the 4 observed practice patterns from 2016 to
2022: ongoing ETI, ongoing SGA use, transition from ETI to SGA use (ETI to SGA), or
transition from SGA use to ETI (SGA to ETI). There was a significant increase in SGA use
in EMS agencies transitioning from ETI to SGA use (P for trendNo. (%) of patients
with OHCA
(n = 63 877)
Outcomeb
Return of spontaneous circulation Survival to hospital discharge
Survival with good neurologic
recoveryc
AOR (95% CI) P value AOR (95% CI) P value AOR (95% CI) P value
Ongoing ETI 18 (34.6) 17 758 (27.8) 0.76 (0.72-0.82)new device
implementation periods; however, we attempted to mitigate this limitation by excluding 2019 OHCAs
in EMS agency practice pattern classifications.
Conclusions
In this cross-sectional study, AA practice patterns of EMS agencies during OHCA varied from 2016
through 2022, with increasing SGA use. Although ROSC, survival to hospital discharge, and survival
with good neurologic recovery declined overall, transition from ETI to SGA use in lower-performing
agencies was associated with improved outcomes. Future studies are needed to validate these findings
and to evaluate whether the observed associations are consistent across diverse populations.
ARTICLE INFORMATION
Accepted for Publication: July 12, 2025.
Published: September 17, 2025. doi:10.1001/jamanetworkopen.2025.32334
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2025 Nassal MMJ
et al. JAMA Network Open.
Corresponding Author: Michelle M. J. Nassal, MD, PhD, Department of Emergency Medicine, The Ohio State
University, 376 W 10th St, 760B Prior Hall, Columbus, OH 43210 (michelle.nassal@osumc.edu).
Author Affiliations: Department of Emergency Medicine, The Ohio State University, Columbus (Nassal, Panchal,
Wang); Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas (Yang);
Department of Emergency Medicine, University of Washington and Harborview Medical Center, Seattle (Hall,
Latimer, Rea, Johnson); Emergency Medical Services Division of Public Health, Seattle & King County, Seattle,
Washington (Shin); National Registry of Emergency Medical Technicians, Columbus, Ohio (Gage); ImageTrend LLC,
Eagan, Minnesota (Powell).
Author Contributions: Drs Nassal and Johnson had full access to all of the data in the study and take responsibility
for the integrity of the data and the accuracy of the data analysis.
Concept and design: Nassal, Shin, Gage, Panchal, Latimer, Wang, Johnson.
Acquisition, analysis, or interpretation of data: Nassal, Yang, Hall, Shin, Powell, Panchal, Latimer, Wang, Rea.
Drafting of the manuscript: Nassal, Gage, Latimer, Wang.
Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Nassal, Hall, Gage, Powell, Panchal, Latimer.
Obtained funding: Nassal, Wang.
JAMA Network Open | Emergency Medicine Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes
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Administrative, technical, or material support: Shin, Panchal, Latimer.
Supervision: Panchal, Latimer, Wang, Rea, Johnson.
Conflict of Interest Disclosures: Dr Nassal reported serving on the Guidelines Committee for the American Heart
Association (AHA) and as a board member of the Central Ohio Cardiac Arrest Registry to Enhance Survival. Dr
Wang reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) during the conduct of
the study. Dr Johnson reported receiving grants from the National Institutes of Health, the Centers for Disease
Control and Prevention, and the AHA outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by grant 1K08HL168330-01 from the NHLBI (Dr Nassal).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank Troy Acker, EMT (The Ohio State University Center for Emergency Medical
Services), for his efforts in developing this initial project. No financial compensation was provided for this
contribution.
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SUPPLEMENT 1.
eFigure. Random Sampling of Emergency Medical Service (EMS) Agencies’ Endotracheal Tube (ETT) and
Supraglottic Airway (SGA) Device Use, 2016-2022
eTable 1. Outcomes for Each Cohort
eTable 2. Mixed-Effects Model for Return of Spontaneous Circulation Adjusted for Utstein Variables as Fixed
Effects and Emergency Medical Services Agency as a Random Effect
eTable 3. Top 3 Survival Quartiles Mixed-Effects Models for Out-of-Hospital Cardiac Arrest Outcomes
eTable 4. Bottom Quartile of Unadjusted Out-of-Hospital Cardiac Arrest Outcomes
SUPPLEMENT 2.
Data Sharing Statement
JAMA Network Open | Emergency Medicine Advanced Airway Practice Patterns and Out-of-Hospital Cardiac Arrest Outcomes
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