Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following authors have no conflicts of interest to declare: Nicole Yamada, Bin Huey Quek, Maha Aly, Jennifer Dawson, Michael Wagner, Helen Liley, and Anne Lee Solevåg. The following authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest Committee: Gary Weiner is a co-author of one included study and was excluded from study selection and bias assessment for this study.1
CoSTR Citation
Yamada N, Quek BH, Aly M, Dawson J, Wagner M, Liley H, Solevåg A, Weiner GM on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Supraglottic airway devices compared to tracheal tubes for neonatal resuscitation, Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, ________2026.
Background
Ventilation of the newborn infant’s lungs is the single most important component of neonatal resuscitation and determining the most effective interface for administering assisted ventilation is a clinical and research priority. During neonatal resuscitation, tracheal tubes are most frequently used as a back-up or secondary device after ventilation attempts with a face mask have failed. An international registry study found that 4.3% of all newborn infants will receive non-invasive ventilation with a face mask and nearly 25% of these infants will undergo tracheal intubation and subsequent invasive ventilation.2 However, achieving and maintaining proficiency in tracheal intubation requires significant training and experience. An international registry demonstrated that only 46% of attempted tracheal intubations during neonatal resuscitation are successful on the first attempt.3 Even with training, tracheal intubation may require multiple attempts over a prolonged time and has been associated with adverse events.3-5 In North America, less than half of neonatology trainees achieve procedural competence in tracheal intubation, defined as 80% overall success within two attempts, at the conclusion of training.6 Supraglottic airway devices have been shown to be effective alternatives to face mask ventilation and as airway rescue devices when tracheal intubation is not successful.7, 8 They may require less training to achieve insertion proficiency and fewer attempts to achieve a successful airway than tracheal intubation.9
The continuous evidence evaluation process to produce this Consensus on Science with Treatment Recommendations (CoSTR) followed ILCOR guidelines.10 The International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force (NLS TF) has identified the comparison of supraglottic airway device and tracheal intubation as a priority for review. The topic (NRP 618) was last reviewed in 2015.11 At that time, one small, randomized trial was included. An evidence update completed in 2024 (NLS 5341) identified three additional potentially eligible randomized controlled trials and one observational study suggesting that an updated systematic review was needed.12
All evidence identified was considered by the Neonatal 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.
Review Citation
Yamada N, Quek BH, Aly M, Dawson J, Wagner M, Liley H, Solevag A, Weiner GM on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Supraglottic airway devices compared to tracheal tubes for neonatal resuscitation: A systematic review. In draft.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Newborn infants receiving assisted ventilation immediately after birth
Intervention: Insertion of a supraglottic airway device
Comparators: Tracheal intubation
Outcomes:
- Successful ventilation with the device (important)
- First attempt successful device insertion (important)
- Number of attempts required for successful device insertion
- Time (seconds) to successful device insertion (important)
- Adverse events during initial hospital stay (important)
- Survival to hospital discharge (critical)
The prioritization of critical and important outcomes was made according to a consensus of international neonatal resuscitation experts or by Task Force consensus.13
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) and cadaver, manikin, and animal studies were excluded.
Timeframe: All years and all languages were included as long as there was an English abstract.
The literature search strategy was developed by a research librarian. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and CINAHL were searched from inception date until September 20, 2025. The literature search was updated on March 20, 2026.
Registration: PROSPERO Registration CRD420251153374 (Registered October 2025). Screening for eligible studies began after the protocol was registered.
Risk of Bias: Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs or the Robins-I version 2 tool for observational studies.14, 15 Additional information from study investigators was sought if required information was unclear or unavailable in the study publications/reports. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to assess the certainty of evidence (COE) for each outcome deemed critical or important.16
Consensus on Science
The search identified five studies comparing supraglottic airway devices with tracheal intubation. Of these, four were small randomized or quasi-randomized clinical trials including newborn infants receiving assisted ventilation immediately after birth.17, 18 19, 20 One was an observational study in a single center describing the method of ventilation used to support newborn late preterm infants during a 5-year study period.1
For the important outcome of successful ventilation with the device, low certainty evidence (downgraded for risk of bias and imprecision) from 4 randomized trials17-20 involving 238 newborn infants could not exclude benefit or harm from providing ventilation through a supraglottic airway device compared with a tracheal tube (RR 0.98, 95% CI 0.93 to 1.03; I2 = 16%; or 19 fewer infants successfully ventilated/1,000 with a supraglottic airway device [95% CI 68 fewer to 20 more] compared to a tracheal tube). Low certainty evidence (downgraded for risk of bias and imprecision) from 1 observational study1 involving 52 newborn infants could not exclude benefit or harm from providing ventilation through a supraglottic airway device compared with a tracheal tube (OR 2.33, 95% CI 0.14 to 39.82; or 30 more infants successfully ventilated per 1,000 with a supraglottic airway device [95% CI 100 fewer to 160 more] compared to a tracheal tube).
For the important outcome of first attempt successful insertion, low certainty evidence (downgraded for risk of bias and imprecision) from 3 randomized trials17, 19, 20 involving 188 newborn infants could not exclude benefit or harm from providing ventilation through a supraglottic airway device compared with a tracheal tube (RR 0.98, 95% CI 0.91 to 1.06; I2 = 0%; or 19 fewer first attempt successful insertions/1,000 with a supraglottic airway device [95% CI 85 fewer to 57 more] compared to a tracheal tube).
For the important outcome of time to successful insertion, low certainty evidence (downgraded for risk of bias and inconsistency) from 3 randomized trials17, 19, 20 involving 188 newborn infants found no important difference between a supraglottic airway device and a tracheal tube (mean difference -0.51 seconds, 95% CI -1.05 to 0.04 seconds; I2 = 98%)
For the important outcome of adverse events, low certainty evidence (downgraded for risk of bias and imprecision) from 2 randomized trials17, 19 involving 108 newborn infants could not exclude benefit or harm from providing ventilation through a supraglottic airway device compared with a tracheal tube (RR 1.22, 95% CI 0.50 to 3.00; I2 = 24%; or 30 more adverse events/1,000 with a supraglottic airway device [95% CI 67 fewer to 269 more] compared to a tracheal tube).
For the critical outcome of survival to discharge, low certainty evidence (downgraded for risk of bias and imprecision) from 1 randomized trial19 involving 68 newborn infants could not exclude benefit or harm from providing ventilation through a supraglottic airway device compared with a tracheal tube (RR 1.03, 95% CI 0.95 to 1.12; or 29 more surviving to discharge/1,000 with a supraglottic airway device [95% CI 48 fewer to 116 more] compared to a tracheal tube).
Treatment Recommendation
- Depending on resources and training, when ventilation with a face mask is not successful or not feasible, we suggest inserting either an appropriately sized supraglottic airway device or an appropriately sized tracheal tube. (Conditional recommendation, low certainty of evidence)
- If face mask ventilation is not effective and tracheal intubation is not feasible or not successful, we recommend inserting an appropriately sized supraglottic airway device. (Implementation consideration)
Justification and Evidence to Decision Framework Highlights
In making this recommendation for newborn infants requiring assisted ventilation when face mask ventilation is not successful or not feasible, the Task Force considered that both tracheal intubation and insertion of a supraglottic airway device were very successful interventions. In a small number of randomized trials, the summary effect estimates for critical and important outcomes were near the null threshold suggesting little difference between the two interventions. However, the certainty of evidence for key outcomes was low due to serious risk of bias and imprecision. The confidence intervals around key outcomes included the possibility of both harm and benefit for both interventions. Indirect evidence suggests that introduction of supraglottic airway devices as an alternative to tracheal intubation is likely acceptable and feasible.21-23 International neonatal resuscitation training programs already include these devices.24, 25 The cost, resources, equity, and safety of either intervention were not directly assessed in the included studies.
Indirect evidence from registry studies suggests that successful insertion on the first attempt for tracheal intubation in clinical practice may be overestimated by the included studies.3, 26, 27 Although successful insertion of a supraglottic airway device may require less training than tracheal intubation, they may not be widely available and health care professionals may lack training and competence in their use.28-30
In the setting of a difficult airway, when ventilation with a face mask fails to achieve an adequate response and tracheal intubation is not successful or not feasible (“Cannot oxygenate, cannot intubate”), international guidelines consistently recommend a supraglottic airway device as the initial adjunctive airway device.31, 32
Knowledge Gaps
- It is not known if a supraglottic airway device decreases the time required to achieve effective ventilation.
- It is not known if supraglottic airway devices are effective and safe for use among preterm infants less than 34 weeks’ gestation or less than 2000 grams birthweight.
- The training and resource requirements needed to achieve and maintain proficiency with supraglottic airway insertion compared with tracheal intubation among health care professionals with varying levels of experience are not known.
- The cost-effectiveness and impact on health equity of widespread supraglottic airway device implementation are not known.
Evidence to Decision (EtD) Tables
NLS 5341 SGAD vs TT Et D Table 11 12 2026
NLS 5341 SGAD vs TT SOF Table 11 12 2026
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