Conflict of Interest Declaration
The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest Committee:
Jerry Nolan is Editor-in-Chief of Resuscitation for which he receives an honorarium; he is a co-author of one of the studies in this review but did not contribute to the data extraction or risk of bias assessment for this study.
Jasmeet Soar is an Editor of Resuscitation for which he receives an honorarium.
CoSTR Citation
Wittig J, Sommer A, Soar J, Böttiger BW, Lavonas E, Moskowitz A, Nolan JP, on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force. Supraglottic airway devices for adult cardiac arrest, Consensus on Science with Treatment Recommendations: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, September 2026
Background
This process began with PROSPERO registration CRD420261392478. All evidence identified was considered by the Advanced Life Support Task Force and is described below. Discussion points and highlights of the evidence-to-decision process are also included. All data were considered when formulating the Treatment Recommendations. Data tables and the evidence-to-decision framework are provided as attachments.
Definitions
A supraglottic airway is defined as a device designed to maintain a patent airway by sitting above the glottis without passing through the trachea. They are usually inserted blindly without the need for laryngoscopy.
A laryngeal mask airway (LMA) is defined as an SGA with an inflatable cuff. The original Classic LMA (cLMA) is a first-generation SGA that is reusable. 2nd generation SGAs have specific design features to reduce the risk of aspiration. Single-use 2nd generation LMAs include the LMA Supreme®, the Ambu AuraGain®, the Air-Q.
A gel-cuff SGA is a single-use, 2nd generation SGA which has a preformed gel cuff instead of an inflatable. At the time of our literature search the i-gel® was the only example of this.
A laryngeal tube (LT) is an airway tube with 2 inflatable cuffs – a smaller distal cuff is intended to sit in the esophageal inlet and the larger proximal cuff sits in the oropharynx. There are multiple variants of the LT such as the King LT, LT-Suction (LTS) and a disposable version of the LTS (LTS-D). The LT is sometimes described as an extraglottic device because it sits more proximally in the hypopharynx, but for the purpose of this review we have included it within the definition of a supraglottic airway.
Review Citation
Wittig J, Sommer A, Soar J, Böttiger BW, Lavonas E, Moskowitz A, Nolan JP.
Supraglottic airway devices for adult cardiac arrest: A systematic review in preparation
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adult patients in cardiac arrest in any setting (in-hospital or out-of-hospital) who require a supraglottic airway during resuscitation
Intervention: Use of a supraglottic airway
Comparison: Use of any other supraglottic airway
Outcomes: Critical: return of spontaneous circulation, survival to hospital admission, 30-day or hospital survival; HRQoL outcomes; functional and neurological outcomes (CPC or mRS).
Important: Process metrics including: end-tidal CO2, chest compression fraction, chest compression pause duration.
Important: First pass success; ventilation success, aspiration, misplacement, dislodgement, oropharyngeal injury.
Study Design: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Case reports or series (<10 patients), conference abstracts, trial protocols, manikin studies, and unpublished studies are excluded.
Timeframe: Records published from 01 January 1988 (the year that the laryngeal mask was introduced) until 12 May 2026, and all languages are included as long as there is an English abstract
Registration: PROSPERO registration CRD420261392478
Consensus on Science
Summary
We identified 14 studies that included comparisons of SGAs during cardiac arrest. Of these, four were randomized trials: one compared the laryngeal tube (LT) with a 1st generation laryngeal mask airway (Ambu Aura-i LMA®);1 one compared a gel-cuff SGA with a 2nd generation LMA (Supreme LMA®);2 one compared the LMA (type unspecified) with the laryngeal tube;3 and one compared the gel-cuff SGA with the Portex Soft Seal LMA®.4 Of the ten non-randomized studies, four compared the gel-cuff SGA with the LT;5-8 two compared the LMA with the LT;9,10 two compared the LMA with esophageal obturator airway (EOA);11,12 one compared the LMA with esophageal-tracheal combitube (ETC);13 and one compared the LMA with the ETC and the esophageal gastric tube airway.14 All studies were for out of hospital cardiac arrest. Although children were eligible for inclusion in five studies,1,3,4,6,14 none of those studies documented the number of children included. One of these studies reported the adjusted odds ratio for survival in a subgroup < 18 years.6
Because each comparison was informed by few studies with differing devices, comparators and outcome definitions, and because most non-randomised studies were at critical risk of bias, no pooled estimates were calculated. Results are presented as forest plots without pooling and summarised narratively.
The key characteristics of the randomized trials are listed in Table 1 and those of the non-randomized studies are listed in Table 2 (see separate document).
Gel-cuff SGA versus laryngeal mask
Neurological outcome and health-related quality of life (critical)
For health-related quality of life (QoL), we found very-low certainty evidence (downgraded for risk of bias and imprecision) from one cluster-randomized feasibility trial that assessed QoL at 90 days among cardiac arrest survivors with an gel-cuff SGA (n=16) and LMA Supreme (n=11)) using the Short Form (36) Health Survey (SF-36).2 The SF-36 physical component score for the gel-cuff SGA was 43.9 ± 11.4 vs 41.5 ± 11.3 for the LMA Supreme (P=NS). The SF-36 mental component score for the gel-cuff SGA was 47.7 ± 11.1 vs 50.4 ± 8.2 for the LMA Supreme (P=NS).
Mid-term survival (survival to hospital discharge, 30-day, or 1-month survival) (critical)
For the critical outcome of mid-term survival, we identified very low-certainty evidence (downgraded for risk of bias, inconsistency of comparator, and imprecision) from one feasibility RCT (n =406): survival to hospital discharge was 10.3% (24/232) with the gel-cuff SGA versus 8.0% (14/174) with the LMA Supreme (OR 1.3295% CI 0.63, 2.85).2
Return of spontaneous circulation (critical)
Very low certainty evidence (downgraded for risk of bias, inconsistent comparator, imprecision) from two RCTs, showed no significant difference in ROSC between the gel-cuff SGA and LMA.2 4
Successful SGA insertion or ventilation (important)
Low-certainty evidence (downgraded for risk of bias and inconsistent comparators) from 2 RCTs compared insertion or ventilation success between gel-cuff SGA and LMA. One study (n = 406) compared the gel-cuff SGA with the LMA Supreme® and found no difference for first -pass success (OR 1.23, 95% CI 0.75–2.01).2 Another small study (n = 48) documented higher ventilation success with the gel-cuff SGA compared with the Portex SoftSeal® LMA (OR 6.5; 95% CI 1.17, 69).4
Gel-cuff SGA versus laryngeal tube
Neurological outcome (critical)
Very low-certainty evidence (downgraded for risk of bias) from a registry study (Cardiac Arrest Registry to Enhance Survival (CARES); n=167,634) documented greater neurologically favourable survival (CPC 1–2 at discharge) associated with the gel-cuff SGA compared with the LT (aOR 1.45; 95% CI 1.33–1.58).6
Mid-term survival (survival to hospital discharge, 30-day, or 1-month survival) (critical)
We identified very low-certainty evidence (downgraded for risk of bias) from two large retrospective registry studies.5,6 In a CARES registry study (n=167,904), use of a gel-cuff SGA was associated with greater survival to hospital discharge than the LT (adjusted OR [aOR] 1.35; 95% CI 1.26–1.46).6 In the ESO Collaborative dataset with hospital disposition recorded (n =7,576), the gel-cuff SGA was associated with greater survival to discharge home (aOR 1.36, 95% CI 1.06–1.76;).5 There may be overlap in these two registry studies because it is possible that some patients were entered in both registries but neither registry was able to measure this. A third, much smaller study (n=250) reported unadjusted 30-day survival (OR 9.5; 1.49, 397), but given the very few survivors, it adds little to the two larger registry studies.8
Return of spontaneous circulation (critical)
The CARES registry and ESO dataset provide very low-certainty (downgraded for risk of bias and inconsistent evidence for ROSC rates with the gel-cuff SGA and LT). The ESO dataset found rates of any ROSC significantly higher with the gel-cuff SGA (aOR 1.19, 95% CI 1.13–1.26, n=73,207).5 The CARES dataset found no significant difference in sustained ROSC between the two devices (aOR 1.03, 95% CI 0.99–1.08, n = 167,904).6 Differences in definitions of ROSC and approaches to statistical adjustment may account for the discrepant results.
Successful SGA insertion or ventilation (important)
Very low-certainty evidence (downgraded for risk of bias) from three studies documents higher rates of first-pass success5,7 or success with up to two attempts8 with the gel-cuff SGA compared with the LT. First-pass success was higher with the gel-cuff SGA in the ESO dataset (n=93,162; aOR 1.94; 95% CI 1.79, 2.09),5 and in a Canadian dataset (n = 2,680), (OR 2.94; 95% CI 2.35, 3.60).7 In a Norwegian study (n=250), success within two attempts was higher with the gel-cuff SGA (OR 2.03; 1.04, 3.95).8 In the CARES registry study, use of the gel-cuff SGA was associated with lower odds of having ETCO2 ≤ 5 mmHg (aOR 0.81; 0.70, 0.95]) or ETCO2 ≤ 10mmHg (aOR 0.84; 0.76, 0.94) among patients who had at least one ETCO2 value recorded and no tracheal intubation attempts recorded during their care.6
Complications (important)
A small non-randomised Norwegian study (n = 250) found no overall difference in complications between the gel-cuff SGA and LT. No statistical difference in air leak was identified with the gel-cuff SGA compared with the LT (OR 2.59; 95% CI 0.95, 8.87).8
Laryngeal tube versus laryngeal mask
Neurological outcome (critical)
For neurological outcome, we found very low-certainty evidence (downgraded for risk of bias and imprecision) from one RCT (n = 313) that found similar rates of favourable neurological outcome (CPC 1–2 at one month) with LT and LM (OR 1.12; 95% CI 0.08, 15.57).3 Very low-certainty evidence (downgraded for risk of bias and indirectness), from 2 observational studies indirectly comparing LT and LM (n = 1,1149 and n = 77,33210) reported no difference in favourable neurological outcome (CPC 1-2) at one month or 30 days (OR 1.26; 95% CI 0.76, 2.11 and OR 0.81; 0.58, 1.12).
Mid-term survival (survival to hospital discharge, 30-day, or 1-month survival) (critical)
For the critical outcome of mid-term survival, we identified very low-certainty evidence (downgraded for risk of bias, inconsistency of comparator, and imprecision) from one cluster-randomised crossover trial (n = 313): 1-month survival was 6.1% (9/148) with the LT versus 4.2% (7/165) with the LMA (OR 1.46 (95% CI 0.47, 4.74).3
Very low certainty evidence (downgraded for risk of bias and indirectness) from one study compared 30-day survival with the LT versus LMA (n = 1,114; OR 0.99; 95% CI 0.70, 1.41)9
Return of spontaneous circulation (critical)
Very low certainty evidence (downgraded for risk of bias, inconsistent comparator, imprecision) from two RCTs showed no significant difference in ROSC between the LT and LMA.1,3
Very low-certainty evidence (downgraded for risk of bias and indirectness) from one non-randomised study found no difference in ROSC rates between an LMA and LT. 9
Successful SGA insertion or ventilation (important)
Low-certainty evidence (downgraded for risk of bias and inconsistent comparators) from two RCTs compared insertion or ventilation success between the LT and LM. One study (n = 900) found placement success significantly lower with the LT than the Ambu Aura-i LMA (aOR 0.53, 95% CI 0.37–0.77).1 Another study (n = 313) found no difference in successful ventilation between the LT and LMA (OR 0.84; 0.48, 1.46).3
Complications (important)
Very low-certainty evidence (downgraded for risk of bias and imprecision) from one randomized trial comparing the LT with the Ambu Aura-i LMA found complications (misplacement, dislodgement, bleeding, tongue/pharyngeal swelling) overall significantly more common with the LT (aOR 2.82, 95% CI 1.64–4.86, n=905).1 The single complication with a significant difference was dislodgement (OR 3.04; 95% CI 1.51, 6.20).
Other SGA comparisons
Neurological outcome (critical)
Very low-certainty evidence (downgraded for risk of bias and indirectness), from two observational studies (n=16,60911 and n = 122,19412) reported no difference in the rate of patients who survived with good neurologic outcome (CPC 1–2) when treated with the esophageal obturator airway (EOA) vs LMA (OR 1.25; 95% CI 0.71, 2.19 and OR 1.06; 0.93, 1.20).
Mid-term survival (survival to hospital discharge, 30-day, or 1-month survival) (critical)
Very low certainty evidence (downgraded for risk of bias and indirectness), from one study compared survival to one month with the EOA and LMA (n =122,194; OR 1.06; 0.99, 1.13).12
Return of spontaneous circulation (critical)
Very low-certainty evidence (downgraded for risk of bias and indirectness) from 2 studies found no difference in ROSC rates (defined slightly differently in the studies) between an LMA and EOA,12 and Combitube.13
Successful SGA insertion or ventilation (important)
Very low-certainty evidence (downgraded for risk of bias) from a single large survey-based study, documented insertion and ventilation success with LMA, Combitube, and esophagogastric tube airway (EGTA). 14 This study was published in 1998 and the EGTA and Combitube are now rarely used. For these reasons, no further details are provided here.
Treatment Recommendation or Good Practice Statement
No previous treatment recommendation
When using a supraglottic airway (SGA) during cardiopulmonary resuscitation we suggest a gel-cuff SGA or 2nd generation laryngeal mask in comparison with a laryngeal tube (weak recommendation, very low certainty of evidence).
Justification and Evidence to Decision Framework Highlights
- This topic was prioritized by the Advanced Life Support Task Force because previous reviews have compared tracheal intubation with insertion of a supraglottic airway (SGA) during cardiac arrest, but none have compared one SGA with another SGA.
- There are no studies that compare one SGA with another SGA in in-hospital cardiac arrest. In the absence of these data, the ALS TF has considered the indirect evidence from OHCA studies to be sufficient to include both IHCA and OHCA in our treatment recommendation.
- Although we identified four RCTs, these were all relatively small and underpowered for long-term outcomes. We identified several large observational studies, particularly those comparing the gel-cuff SGA with the LT in cardiac arrest. Some of these studies included analyses that were adjusted to account for confounders; however, it is likely that there were additional unmeasured confounders that were not accounted for.
- Indirect evidence from a large network meta-analysis of randomised controlled trials comparing SGAs for airway management in anaesthetised patients documents first attempt success rate and oropharyngeal leak pressure for a wide range of SGAs.15 In this analysis, first attempt success rates for the LMA Supreme and gel-cuff SGA were higher than for all LT variants; however, oropharyngeal leak pressure was higher for all LT variants than for the gel-cuff SGA.
- 2nd generation LMAs incorporate modifications that may reduce the risk of pulmonary aspiration in comparison with earlier 1st generation devices. Many 2nd generation LMAs also include features that aim to increase oropharyngeal leak pressure. There have been no comparisons of 1st with 2nd generation LMAs in cardiac arrest, but given the high risk of regurgitation, pulmonary aspiration, and high airway pressures during cardiac arrest, if an LMA is to be used during cardiac arrest, it is reasonable to use a 2nd generation instead of a 1st generation LMA.
- The ALS TF noted that some EMS systems had documented trends in the use of SGAs for out-of-hospital cardiac arrest and that these showed increasing use of the gel-cuff SGA and decreasing use of the LT. However, this could reflect marketing strategies rather than preference based on performance of the devices.
Knowledge Gaps
- There is a need for in-hospital randomised controlled trials in adults that compare the clinical effectiveness of SGA types.
- There are no data that compare different SGAs in cardiac arrest of different causes.
Data Tables
ALS 3310 Evidence to Decision Table Et D 26 October2026
ALS 3310 Tables 1 2 for SGA 26 October2026
References
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