A field read on the 2026 narrative review of prehospital airway and ventilatory management — where the real decisions happen before the laryngoscope ever comes out.
Intubation isn't the variable that matters most — who gets intubated is.
The trauma data make the case bluntly. A 2026 causal-modeling study tracking 6,467 trauma patients found prehospital intubation improved 30-day survival — but only when guided by machine-learning risk stratification. Applied indiscriminately, the benefit disappeared. A separate propensity-matched cohort of 840 patients backed this up: no overall ICU mortality difference.
Positive-pressure ventilation drops venous return right when a shock patient can least afford it. The THOR Network's answer is circulation-first: control bleeding and push blood products before advanced airway placement, unless obstruction itself is the immediate threat.
TBI cuts the other way — intubation tracked with meaningfully better neuro outcomes (57.3% vs. 46.0%) and lower mortality (13.8% vs. 19.5%, OR 0.53). But the review pushes back on treating GCS <8 as a standalone trigger; trajectory of decline, mechanism, hemodynamics, and operational context all belong in the decision.
The minutes before you touch the airway are where outcomes get made or lost.
| Finding | Detail |
|---|---|
| Peri-intubation hypotension | Occurs in 25–43% of critically ill prehospital intubations |
| Ketamine vs. etomidate | RSI Trial: ketamine drove more cardiovascular collapse, especially in septic shock — no mortality difference |
| Opioid pretreatment | Best avoided — the one low-risk RCT (n=6,708 review) showed increased post-intubation hypotension (OR 2.15) |
| Rocuronium vs. succinylcholine | CURASMUR: rocuronium fell short of non-inferiority for first-attempt success (74.6% vs. 79.4%) |
Preoxygenation gets its own spotlight, and PREOXI is the study to know: bi-level NIPPV before intubation cut critical desaturation, biggest effect in obese and already-hypoxemic patients. Where NIPPV isn't on the truck, flush-rate nonrebreather — north of 50 L/min — is the fallback. PreVent adds a simple habit: bag-mask ventilation between induction and laryngoscopy meaningfully reduces hypoxemia, with no aspiration signal to justify skipping it.
One large transport cohort: post-intubation hypotension in 15% of cases, peri-intubation arrest in 5%. Strongest predictors — age >65, pre-intubation SBP <130, baseline SpO₂ <90%. CURASMUR clocked a 23.2% first-attempt failure rate, with failed attempts carrying a complication rate nearly a third to a half higher than successful ones.
The review's answer is a staged, pre-committed escalation — bag-mask to supraglottic airway to surgical access — never improvised in the moment. SGA gets promoted here from “backup device” to genuine first-line tool in two specific settings: in OHCA, a 2024 meta-analysis of four RCTs (over 13,000 patients) found SGA delivered faster placement and higher ROSC with equivalent 30-day neurologic survival vs. intubation. And in paramedic-based systems with limited intubation exposure, rapid sequence airway — induction drugs paired with primary SGA placement — is framed as a clinically defensible first choice, not a fallback.
CPAP/BiPAP have earned their place. HFNO is still mostly a promise.
A meta-analysis confirms prehospital CPAP cuts both intubation rates and mortality in acute cardiogenic pulmonary edema. Bilevel NIV's evidence base is thinner, and prehospital COPD data thinner still. HFNO is where the honesty is sharpest — the prehospital evidence is described as essentially case reports and small series.
Experimental data cited in the review show ambient oxygen concentration inside poorly ventilated transport cabins can climb to genuine fire-hazard levels during HFNO use. Cylinder depletion and battery-dependent humidification round out the practical failure modes — know your oxygen and power reserves before you commit to a transport duration.
None of this is radical. What it is, taken together, is a decent argument that “airway management” was never really about the tube. It's about the sequence of decisions around it — physiologic optimization before the laryngoscope, a pre-committed escalation pathway instead of improvisation, SGA treated as a legitimate primary strategy rather than a consolation prize, and NIV/HFNO used without ever letting them delay definitive control when deterioration demands it. This review is a useful, current stake in the ground for what that sequence should look like.