Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Basic Life Support (BLS) Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none
The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chair:
- Nicholas Johnson is a co-investigator for the First Responder Airway and Compression Trial (FACT, NCT05969028), which compares supraglottic airway and mask ventilation among BLS providers.
- Guillaume Debaty and Nicolas Segond received funding from the University of Grenoble Alps for a cadaver study that compared supraglottic airway and mask ventilation among BLS providers.
- Gavin Perkins received research funding from the National Institute For Health And Social Care Research related to airway management during in-hospital cardiac arrest (AIRWAYS3).
- The other authors did not declare any conflicts.
- The SAC rep has no COI to disclose on this subject
These conflicts were declared in meetings but did not require specific management during the CoSTR process.
CoSTR Citation
Debaty G, Johnson N, Perkins G, Dassanayake V, Snow L, Segond N, Morrison LJ, Bray J -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Airway management with a supraglottic airway device during resuscitation by basic life support providers Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2025 March 20. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
Previous systematic reviews by the ALS task force 1 and by the PLS task force2 did not address the specific setting of BLS providers independently.
The continuous evidence evaluation process for the production of this Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review by members of the basic life support task force (PROSPERO CRD42024592988). Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Adult Task Force. Additional scientific literature on simulations studies in non-EMS responders was also collected after the completion of the systematic review and is described in the justifications and evidence to decision highlights section of this CoSTR. The systematic review and simulation data were taken into account when formulating the Treatment Recommendations.
Systematic Review
Debaty G, Johnson N, Perkins G, Dassanayake V, Snow L, Segond N, Morrison LJ, Bray J -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Airway management with a supraglottic airway device during resuscitation by basic life support providers: a systematic review. In draft.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults in any setting (out-of-hospital or in-hospital) in cardiac arrest managed by first responders (example police, firefighter) and/or Emergency Medical Services (EMS) Basic Life Support (BLS) providers
Intervention: Airway management with a supraglottic airway device during resuscitation by basic life support provider(s)
Comparators: Facemask airway management with or without oropharyngeal or nasopharyngeal airway.
Outcomes: Clinical outcomes identified by the BLS Task Force a priori as: critical include survival to hospital discharge with favorable neurological outcome, survival to hospital discharge/30 days; and important include survival after hospital discharge/30 days (e.g. 90 days, 180 days, 1 year), return of spontaneous circulation, first pass success, time to successful insertion, CPR quality (compression fraction, successful ventilation, respiratory rate, tidal volume), the need for further airway interventions, regurgitation and aspiration pneumonia.
Study Designs:
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.
Animal studies, manikin/simulation, cadaver studies and Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract.
Timeframe: All years to database inception. Search was last updated on October 20th, 2025.
PROSPERO Registration CRD42024592988
Consensus on Science
No evidence was identified for community or dispatched First Responders (e.g. firefighters, police). Among the 16 studies included, 3 were RCTS 3-5 and 13 were observational 6-18, with 14 focused on emergency medical service (EMS) personnel (including emergency technicians and paramedics). The remaining two studies involved basic life support trained nurses without prior training in tracheal intubation 4,16. The Stone study16, an in-hospital study, was included because of the lack of evidence in the EMS studies for the outcome of regurgitation.
In seven studies, there was either a mix of supraglottic airway devices (laryngeal mask, laryngeal tube, esophageal-tracheal twin-lumen airway) included or the type of airway device used was not specified 3,6,8,10,11,14,15. Four studies specifically studied a laryngeal tube 4,5,7,12 and five studies a laryngeal mask 9,13,16-18. All studies compared to bag-valve-mask (BVM) ventilation, but most studies did not detail oropharyngeal airway use. In several observational studies, BVM was used prior to SGA 4,6-9,11,14-18.
Survival to hospital discharge with favorable neurological outcome:
For the critical outcome of survival to hospital discharge with favorable neurological outcome, we identified very low certainty evidence (downgraded for serious risk of bias, very serious inconsistencies and serious imprecision) from eight observational studies 6,7,10-12,14,15,18 including 754,697 adult patients with out-of-hospital cardiac arrest (OHCA). Meta-analysis was not possible due to methodological and statistical heterogeneity. For this outcome in OHCA, three studies reported no statistical difference for adjusted odds of survival with favorable neurological outcome 7,11,18 and three studies reported decreased adjusted odds of survival with SGAs10,14,15. Results were similar with unadjusted odds of survival with favorable neurological outcome with four studies no statistical difference 6,7,15,18 and four studies reported decreased unadjusted odds of survival with SGAs 10-12,14. Although no study adjusted for the duration of resuscitation.
Survival to hospital discharge or 30 days:
For the critical outcome of survival to hospital discharge or 30 days, we identified moderate certainty evidence (downgraded for serious risk of bias) from three randomized controlled trials (RCTs) 3-5 including 628 adult patients with OHCA. Meta-analysis showed no significant difference with the use of a SGA when compared with BVM (RR 1.28; 95% CI 0.46 to 3.55; I2=0%; 8 more patients per 1 000 survived to hospital discharge or 30 days with SGA [95% CI from 16 fewer to 74 more/1000].
For the critical outcome of survival to hospital discharge or 30 days, we identified very low certainty evidence (downgraded for serious risk of bias, very serious inconsistencies and serious imprecision) from nine observational studies including 688,339 adult patients with OHCA 7-9,11,12,14,15,17,18 Meta-analysis was not possible due to methodological and statistical heterogeneity.
For this outcome, three studies reported no statistical difference for adjusted odds of survival 7,8,11, three studies report decreased adjusted odds of survival with SGA 12,14,18 and one study reported increase in adjusted odds of survival with SGA15.
Results were similar with unadjusted odds of survival, five studies reported no statistical difference for unadjusted odds of survival 7,11,15,17,18, three studies report decreased unadjusted odds of survival with SGA 8,12,14 and one study reported increase in unadjusted odds of survival with SGA 9.
Return of Spontaneous Circulation (ROSC):
For the important outcome of ROSC, we identified very low certainty evidence (downgraded for very serious risk of bias and serious imprecision) from two RCTs 4,5 including 158 adult patients with OHCA which showed no significant differences with the use of a SGA when compared with BVM (RR 1.08; 95% CI 0.58 to 2.00; 9 fewer patients per 1 000 had ROSC with the intervention [95% CI from 24 fewer to 10 more /1000].
For the important outcome of ROSC, we identified very low certainty evidence (downgraded for serious risk of bias, very serious inconsistencies and serious imprecision) from 11 observational studies 6,7,9-15,17,18 including 756 174 adult patients with OHCA. Meta-analysis was not possible due to methodological and statistical heterogeneity. For this outcome, six studies reported no statistical difference for adjusted odds of survival 6,7,9,11,13,17,18, three studies report decreased in unadjusted odds of ROSC with SGAs 10,12,14 and one study reported increase in ROSC with SGAS15. Adjusted odds of ROSC were available in only three studies, one study reported decrease in adjusted odds of ROSC with SGAs14 and two studies reported no statistical differences 7,18.
Regurgitation:
For the important outcome of regurgitation, we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from two randomized controlled trial 4,5 including 158 adult patients with OHCA which showed no significant difference in rates of regurgitation (RR 0.99; 95% CI 0.46 to 2.11; one fewer patients per 1 000 had regurgitation with the intervention [95% CI from 79 fewer to 162 more /1000]). In a third RCT 3 included 470 patients, regurgitation were observed in 30% of patients before randomization and a further 10% vomited during or after insertion. There was no differences observed in proportion between devices (in the SGA groups between 31% with Laryngeal mask and 42.5% with combitube, and 42.5% in the BVM group).
For the important outcome of regurgitation, we identified very low certainty evidence (downgraded for very serious risk of bias and indirectness) from two observational studies, one 7 included 469 adult patients with OHCA and one 16 included 722 adult patients with in-hospital CA. Meta-analysis was not possible due to methodological and statistical heterogeneity. One study showed no statistical differences (22/395 (5.5%) vs. 8/74 (11%), p=0.10) 7 and one study showed a decreased in unadjusted rates of regurgitation with the use of a SGA when compared with BVM 16. In that study, regurgitation occurred in 3/86 (3.5%) patients that received ventilation using SGA only compared to 58/466 (12.4%) in patients with BVM only, p=0.02. Patients receiving BVM then SGA presented regurgitation more frequently 20/170 (11.8%).
Chest compression fraction:
For the important outcome of chest compression fraction we identified low certainty evidence (downgraded for serious risk of bias and serious imprecision) from one RCT 4 including 82 adult patients with OHCA which showed significantly higher chest compression fraction with the use of a supraglottic airway when compared with bag mask ventilation: 75% (interquartile range [IQR]=68-79%) vs. 59% (IQR=51-68%) (p<0.01).
For the important outcome of chest compression fraction, we identified low certainty evidence (downgraded for serious risk of bias) from one observational study 12 including 1220 adult patients with OHCA. This study showed a significant increase in chest compression fraction with the use of a SGA when compared with BVM 12.
Ventilation success:
For the important outcome of ventilation success, we identified very low certainty evidence (downgraded for various serious risk of bias and various serious imprecision) from one observational study 7 including 469 adult patients with OHCA. This study showed a significant increase in ventilation success with the use of a SGA when compared with BVM (367/395 (92.9%) vs. 28/74 (37.8%), p<0.01).
Treatment Recommendations and Good Practice Statements
For BLS-trained emergency medical services personnel (i.e. paramedics, nurses and emergency medical technicians), we suggest using bag-valve ventilation with a supraglottic airway or bag-valve mask with or without oropharyngeal/nasopharyngeal airway (weak recommendation, very low-certainty evidence).
We support the use of bag-valve ventilation with a supraglottic airway or bag-valve mask with or without oropharyngeal/nasopharyngeal airway by appropriately BLS-trained volunteer community responders or dispatched first responders (e.g., firefighters, police, lifeguards) (Good practice statement).
We support a competency-based training program with regular retraining for both bag-valve mask ventilation and airway insertion (Good practice statement).
Justification and Evidence to Decision Framework Highlights
Most published studies were in basic life support trained emergency medical technicians, with two studies in nurses untrained to perform endotracheal intubation. There were no studies in other basic life support providers (volunteer or first responders). According to Utstein definition, a volunteer community responder is someone alerted to the scene, first responders are non-EMS dispatched to the scene (eg, fire, police) and EMS responders have the ability to transport the patient to hospital.
The existing, generally very low-quality evidence. The three RCTs report no difference in patient outcomes between a BVM and SGA, whereas the observational results were more varied.
Indirect evidence from feasibility and implementation studies indicates that the use of supraglottic airway devices (i-gels) by firefighters is safe and can be introduced with appropriate training19-22. Data from simulation and cadaver studies involving first responders (including lifeguards, mountain rescue teams, and volunteer responders) suggest that the use of various supraglottic airway devices is feasible 23, may improve ventilation success rates with appropriate training24 and shows no significant differences in usability compared to advanced life support providers 25.
Several observational studies were at significant risk of bias as the use of supraglottic airway was at the discretion of EMS with no adjustment for confounders 6-11,14-18. There was also considerable heterogeneity among the studies, limiting the conclusions. Meta-analysis was not possible in observational studies due to this methodological and statistical heterogeneity. Moreover, in several observational studies, BVM was used prior to SGA 4,6-9,11,14-18; thus the quality of ventilation before-and-after the switch and the timing of the switch in the intervention limits the interpretation of the results.
The included observational studies are a risk of resuscitation time bias (i.e. SGA are more likely to be used in longer resuscitations). No study used methods to adjust for this bias in either their multivariable models or propensity analysis 26.
There are insufficient data to express a preference for a particular supraglottic airway device over BVM. Due to the limited evidence, we pooled data from different supraglottic airway devices; however, the performance of individual supraglottic airway devices may vary. However, three observational studies not included have reported higher rates of successful placement with i-gels compared to laryngeal tubes 27-29.
Due to the study design and limited data, we were unable to assess the differences between any of our a priori subgroup considerations (patient gender, basic life support providers (first rescuers, emergency medical technician, other healthcare professional, OHCA vs. IHCA, SGA type).
In this systematic review, face masks were always associated with a self-inflating bag attached to a face mask via a shutter valve (bag-valve mask). Face masks alone were not assessed.
Only one observational study 7 assessed ventilation quality during resuscitation using BVM, with or without the use of a supraglottic airway. As a result, the quality of ventilation delivered by either technique remains uncertain and is likely to vary across providers and devices. Effective BVM is difficult to perform well 30,31, and may require multiple personnel and depend on provider training and skill. The optimal bag-mask technique and the use of airway adjuncts (such as oropharyngeal or nasopharyngeal airways) could not be specifically evaluated. SGAs may be preferred as it provides a more secure seal than BVM ventilation and require fewer hands once the airway is secure. The limited evidence, with very serious risk of bias from observational studies, suggests that SGA may mitigate the risk of regurgitation during CPR.
They are limited evidence from one RCT (low certainty, moderate risk of bias) and one observational study (low certainty serious risk of bias) that SGA may increase hands-on time during CPR.
EtD: BLS 2031 SGA for BLS ETD v4 0 SAC approved
Tables: BLS 2031 SGA for BLS ROB tables; BLS 2031 SGA for BLS Grade Table Final; BLS 2031 SGA for BLS Table summary for justification and ETD
Knowledge Gaps
There was a lack of RCTs comparing the SGA devices.
There was a lack of studies assessing critical outcomes such as favorable neurologic outcome.
Adverse effects were not consistently reported, limiting the analysis on several important outcomes, such as regurgitation and aspiration. No study adjusted for the resuscitation time bias.
Ventilation success was poorly defined and evaluated in trials.
Measures of ventilation quality with either strategy are missing.
Studies were confounded by the presence or absence of multiple levels of paramedic competency in airway management. It is difficult to assess the effect of intervention across a multi-tiered response to cardiac arrest using observational data.
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