Prehospital airway and ventilatory management: a collaborative
and narrative review
Intensive
Care Medicine Published: 02 July 2026
Purpose
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.
Methods
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.
Results
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.
Conclusion
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.
