Supraglottic Airway Devices Improve Clinical Outcomes for Out-of-Hospital Cardiac Arrest: An Updated Systematic Review and Trial Sequential Meta-Analysis Involving 196,573 Patients

OBJECTIVESAlthough several systematic reviews attempted to compare supraglottic airway (SGA) and endotracheal intubation for or adults with out-of-hospital cardiac arrest (OHCA), the optimal airway management strategy remains debated. We conducted a systematic review and meta-analysis comparing supraglottic airway (SGA) devices and endotracheal intubation (ETI) as initial interventions in OHCA to clarify their relative clinical efficacy. DATA SOURCESWe retrieved relevant clinical trials from PubMed, Embase, Cochrane Library, Web of Science, and China National Knowledge Infrastructure(CNKI), as well as unpublished sources, from inception to October 10, 2025. STUDY SELECTIONWe included randomized controlled trials (RCTs) and non-randomized studies involving adult patients with OHCA who were assigned to supraglottic airway (SGA) versus endotracheal intubation for initial prehospital airway management. RESULTSOur systematic review and meta-analysis enrolled 9 randomized controlled trials and 23 non-randomized studies, involving 196,573 patients. Patients who received SGA were associated with higher incidence of return of spontaneous circulation (ROSC), (RCT RR = 1.17, 95% CI: [1.03,1.34], P = 0.016, I{superscript 2} = 48.5%), higher incidence of first-attempt success rates (RCT: RR = 1.31, 95% CI, [1.14-1.51], P = 0.0029. Non-RCTs: RR = 1.46, 95% CI: [1.26,1.70], P < 0.0001, I{superscript 2} = 83.1%), higher incidence of return of time to airway securement (RCT: MD = -2.30 min, 95% CI: [-3.54, -1.05], P = 0.0003, I{superscript 2} = 98.4%. Non-RCTs: MD = -2.86 min, 95% CI: [-3.62, -2.11], P < 0.0001, I{superscript 2} = 95.8%.). There is no difference in favorable neurological outcome (RCT: RR = 1.06, 95% CI: [0.84, 1.35], P = 0.6202, I{superscript 2} = 45.4%. Non-RCTs: RR = 0.94, 95% CI: [ 0.76, 1.18], P = 0.6198, I{superscript 2} = 74.2%.) and no difference in occurrence of regurgitation/aspiration (RR 1.03; 95% CI: [0.93, 1.14]; P=0.5426, I{superscript 2} = 0.0%). Additionally, trial sequential analysis was performed to validate these findings. CONCLUSIONFor adult patients experiencing out-of-hospital cardiac arrest (OHCA), initial airway management by using supraglottic airway (SGA) improves rate of return of spontaneous circulation (ROSC), enables faster airway placement, and achieves higher first-pass success rate when compared with endotracheal intubation. There is a high degree of certainty regarding the major outcomes.