Endotracheal intubation versus the supraglottic airway for resuscitation outcomes in out-of-hospital cardiac arrest: a systematic review and meta-analysis

To assess the safety and efficacy of supraglottic airway (SGA) versus endotracheal intubation (ETI) for improving resuscitation outcomes in patients with out-of-hospital cardiac arrest (OHCA) via a systematic review and meta-analysis. Eight databases, including PubMed, Embase, the Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and CBM, were searched for eligible controlled trials (including both randomized controlled trials and clinical controlled trials) from inception to May 31, 2025. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized controlled trials and the ROBINS-I tool for non-randomized clinical controlled trials. Meta-analysis, sensitivity analysis, and trial sequential analysis (TSA) were performed via RevMan 5.3 and TSA software. The evidence quality was graded via the GRADE framework. The primary outcomes included the airway establishment time and Return of Spontaneous Circulation (ROSC), and the secondary outcomes included the first-attempt advanced airway success, mortality, favorable neurological prognosis, time to return of spontaneous circulation (ROSC), time to SpO2 improvement, peripheral oxygen saturation (SpO2), and adverse events. Thirty-one controlled trials (22,396 patients), comprising 21 randomized controlled trials and 10 clinical controlled trials, were included. Compared with ETI, SGA was associated with a significantly shorter airway establishment time (mean difference (MD) =− 77.93 s; 95% CI (− 100.30, − 55.55 s); P < 0.00001), higher first-attempt advanced airway success (RR: 1.47; 95% CI 1.40, 1.55; P < 0.00001), and improved ROSC (RR: 1.26; 95% CI 1.15, 1.39; P < 0.00001). No significant differences were observed in neurological outcomes (RR: 1.07; 95% CI 0.80, 1.43; P = 0.66), or mortality (RR: 0.99; 95% CI 0.96, 1.03; P = 0.66). Interestingly, SGA reduced the rate of vocal cord injury (RR: 0.11; P = 0.003). The quality of the GRADE evidence ranged from very low to moderate. Compared with ETI, SGA was associated with superior operational efficiency and a favorable safety profile in OHCA resuscitation, particularly in prehospital settings with limited intubation expertise. However, these procedural advantages did not translate into improved neurological outcomes and reduced mortality rate, which were comparable between groups. These findings suggest that SGA represents a viable airway management option during initial resuscitation, particularly when timely ETI cannot be performed by experienced providers. However, given the moderate to very low certainty of evidence and the lack of demonstrated benefit in long-term survival or neurological outcomes, SGA should not be considered superior to ETI, and the choice of device should be guided by system resources, provider expertise, and clinical context rather than a universal preference for either device. Future studies should focus on identifying which patient subgroups or system characteristics benefit most from a specific airway strategy and explore the long-term impact of advanced SGA designs. PROSPERO registration number CRD420251159958.