Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis

Introduction: Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. Methods: A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. Results: Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96–98) vs. 98% (95% CI 91–100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73–89) vs. 82% (95% CI 70–93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98–100) vs. 96% (95% CI 94–97) and first-pass success 89% (95% CI 77–98) vs. 71% (95% CI 57–84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88–100) vs. 98% (95% CI 95–100), but no analysis for physician ground first pass was possible. Conclusions: Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.