Abstract
Evidence comparing supraglottic airway with tracheal intubation in out-of-hospital cardiac arrest remains conflicting, and prior meta-analyses covered few randomized trials. We compared these strategies in adults. PubMed, Embase, and the Cochrane Library were searched from inception to January 2026 for randomized and observational studies comparing the two strategies in adults. Primary outcomes were survival to hospital discharge and return of spontaneous circulation (ROSC); favorable neurological outcome was secondary. Risk of bias was assessed with ROBINS-I and RoB 2, and certainty with GRADE. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using restricted maximum likelihood random-effects models, with heterogeneity (I2), subgroup, sensitivity, meta-regression, and exploratory trial sequential analyses. Thirteen studies (246,659 patients) were included. Survival to hospital discharge did not differ between SGA and TI groups (RR 0.96; 95% CI 0.82-1.12; I2 = 80%). Compared with tracheal intubation, supraglottic airway placement was associated with a lower rate of return of spontaneous circulation (RR 0.86; 95% CI 0.77-0.96; I2 = 96%), particularly in the prehospital setting (RR 0.82; 95% CI 0.71-0.95). The direction of the association differed according to study design: SGA was associated with a lower rate of ROSC than TI in observational studies (RR 0.81; 95% CI 0.73-0.89), whereas SGA was associated with a higher rate of ROSC than TI in the two randomized trials (RR 1.09; 95% CI 1.03-1.16). Favorable neurological outcome did not differ overall (RR 0.99; 95% CI 0.88-1.11; I2 = 61%), although the exploratory subgroup analysis showed a borderline statistically significantly lower rate of favorable neurological outcomes with SGA compared with TI among studies assessing outcomes at ≥1 month after the event (RR 0.90; 95% CI 0.81-0.99). Exploratory trial sequential analyses were overall inconclusive, with more supportive findings observed for ROSC. These exploratory analyses should be interpreted cautiously. In out-of-hospital cardiac arrest, survival to hospital discharge did not differ between strategies, whereas SGA placement, compared with TI, was associated with a lower likelihood of ROSC. In an exploratory subgroup analysis of studies reporting neurological outcomes at ≥1 month after OHCA, TI was associated with a higher likelihood of favorable neurological outcome compared with SGA. Given the mostly observational evidence, substantial heterogeneity, and reversal in randomized trials, these findings are hypothesis-generating and warrant randomized confirmation.
Prospero Registration: CRD420261337076.