Prehospital airway and ventilatory management: a collaborative and narrative review

Prehospital airway and ventilatory management is a frequent, high-stakes and technically demanding component of emergency care. Environmental constraints, limited resources, and variable provider experience make it particularly challenging, and prehospital care systems differ substantially across countries, from paramedic-based to physician-led models, contributing to heterogeneity in clinical practices and patient outcomes. In this narrative review, we discuss evidence-based best practice, including indications, timing, physiological optimization, procedural conduct, and post-intubation management of prehospital tracheal intubation or non-invasive ventilation and high-flow nasal oxygen.

Tracheal intubation remains the definitive airway management strategy when performed for appropriate indications by adequately trained providers. Indications span major trauma, traumatic brain injury, out-of-hospital cardiac arrest, and comatose patients, though its role in comatose poisoned patients is increasingly questioned. Physiology optimization before intubation is a critical and frequently underappreciated determinant of outcome, encompassing preoxygenation with non-invasive positive pressure ventilation, bag-valve-mask ventilation between induction and laryngoscopy, and careful sedative selection to limit peri-intubation hemodynamic compromise.

When intubation fails, a structured escalation strategy including videolaryngoscopy, supraglottic airway devices, and emergency front-of-neck access must be rehearsed and immediately available. In out-of-hospital cardiac arrest, supraglottic airways represent a valid primary alternative with equivalent neurological survival and faster placement. Non-invasive ventilation (primarily CPAP and BiPAP) has a well-established role in acute cardiogenic pulmonary edema and COPD exacerbations, reducing intubation rates and mortality. High-flow nasal oxygen is an emerging modality with strong in-hospital evidence, but prehospital data remain extremely limited and logistical constraints restrict its routine use. Non-invasive support must never delay intubation when clinical deterioration demands it.

Specific contexts require tailored adaptations: altitude physiology in helicopter transport, obesity-specific positioning, cervical spine precautions in neurological injury, comfort-focused strategies in palliative patients, and proactive stabilization before prolonged transport. Evidence gaps remain, particularly regarding prehospital high-flow nasal oxygen.