Airway management during missions of a neurologist-staffed mobile stroke unit: a retrospective registry study

Abstract Background Following their endorsement by international guidelines, mobile stroke units (MSUs) are increasingly being integrated into emergency medical services worldwide. In real-world use, physician-staffed MSUs can be dispatched beyond their intended indication, exposing on-board neurologists to non-stroke emergencies. This raises important clinical and regulatory questions about the competencies MSU physicians need. Advanced airway management is one of the most critical prehospital interventions. Yet, its frequency, indications, procedural characteristics and success rates have not been investigated in neurologist-staffed MSU services. Methods We retrospectively analysed a prospective registry of mission documentation from a neurologist-staffed MSU service in Berlin, Germany from 31 August 2024 to 15 March 2026. Dispatches of the MSU were classified as stroke or non-stroke dispatches using the recorded activation code. The primary outcome was the dispatch-based frequency of endotracheal intubation (ETI), defined as a documented intubation attempt. All ETIs were performed by the on-board neurologist. Secondary outcomes included supraglottic airway (SGA) use, first-pass success rate, procedural characteristics and self-reported post-mission National Aeronautics and Space Administration Task Load Index (NASA-TLX) workload. Proportions are reported with 95% Wilson confidence intervals (CI). Results We analysed 3,887 dispatches. ETI occurred in a total of 49 dispatches (1.26%; 95% CI 0.95–1.66) with 2 in 1,755 stroke- (0.11%; 95% CI 0.03–0.41) and 47 in 2,132 non-stroke dispatches (2.20%; 95% CI 1.66–2.92). SGA use occurred in 22 dispatches (0.57%; 95% CI 0.37–0.86). All 49 intubation attempts were successful (100.0%; 95% CI 92.7–100.0). First-pass success was achieved in 43/49 (87.8%; 95% CI 75.8–94.3) with no ETI requiring more than two attempts. Videolaryngoscopy was used in all ETIs and capnographic confirmation of tube position in 48/49 (98%). Non-traumatic cardiac arrest was the most frequent indication (30/49). In the exploratory workload analysis, the median NASA-TLX score was 59.8 [IQR 50.0–68.7] in 49 dispatches with ETI and 27.0 [15.5–41.7] in 2,700 dispatches without ETI. Conclusions ETI was infrequent overall and particularly rare during stroke dispatches, yet first-pass success was high. Prospective studies are needed to define airway management requirements and training standards for MSU physicians.