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A Systematic Review of
Prehospital Combat Airway Management

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Shane Smith, MD, MSc *; Michael Liu, MD ;
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Ian Ball, MD, MSc ; Bethann Meunier, MD ; Richard Hilsden, MD, MBA 5
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ABSTRACT
Medical leadership must decide how prehospital airways will Methods
be managed in a combat environment, and airway skills can be We conducted a search in Medline and EMBASE databases.
complicated and difficult to learn. Evidence informed airway The search terms included combinations of the following
strategies are essential. A search was conducted in Medline subject headings and keywords: airway, prehospital, crico-
and EMBASE databases for prehospital combat airway use. thyroidotomy, endotracheal intubation, nasopharyngeal, oro-
The primary data of interest was what type of airway was pharyngeal, supraglottic, combat, military medicine, warfare,
used. Other data reviewed included: who performed the in- armed conflict, and battlefield. Searches were restricted to hu-
tervention and the success rate of the intervention. The search mans and adults. No language restrictions were applied. Stud-
strategy produced 2,624 results, of which 18 were included ies of airway techniques performed in the prehospital combat
in the final analysis. Endotracheal intubation, cricothyroidot- environment were included. Studies were excluded if the pa-
omy, supraglottic airways, and nasopharyngeal airways have tients were less than 18 years old, if it was an animal study,
all been used in the prehospital combat environment. This or if it was a case report or review article. Our focus was on
review summarizes the entirety of the available combat lit- the types of airways that were used, the provider type, and
erature such that commanders may make an evidence-based the success rates. Note that for provider type, the language in
informed decision with respect to their airway management each original reference was replicated, with the understanding
policies. the definitions and training requirements for such positions as
paramedic, medic, and combat medic may not be comparable
Keywords: endotracheal intubation; airway; cricothyroidot- between studies. No publication time restrictions were im-
omy; supraglottic airways; and nasopharyngeal airways posed. All studies were uploaded into Cochrane’s Covidence.
org reference management system. This review was registered
on the PROSPERO Registry (2018CRD42018102976). All
Introduction studies were subject to a title and abstract review by two in-
dependent examiners (RH, ML). A third party was used to re-
Military medical leaders must decide how prehospital com- solve any conflicts (SS). Remaining studies were subject to full
bat airways will be managed and what training is required for text screening, in which studies failing the inclusion/exclusion
prehospital providers. As with most wartime medical research, criteria were discarded using the same three-reviewer system.
this area is difficult to study with the same level of method-
ological rigour that is achievable in a civilian environment. Results
Despite the available research being heterogeneous and of The search strategy produced 2,624 results, of which 728 du-
variable quality, it is important to summarize lessons learned plicates were removed. This resulted in 1,896 papers which
during conflicts. were subject to title and abstract review. Of these, 1,825 were
excluded for not meeting inclusion criteria. Seventy-one studies
Airway skills are difficult to learn and maintain. Moreover, underwent full text review. Fifty-two were removed for the fol-
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managing an airway while wearing personal protective equip- lowing reasons: 33 had the incorrect study design, 11 had the
ment in an austere environment poses different challenges than incorrect patient population, three were duplicate studies, four
the civilian prehospital experience. Inadequate training may were the incorrect intervention, and two where the full text was
lead to significant patient morbidity and mortality, as well as unavailable. Eighteen studies were included in the final review,
mental health sequelae to providers. Military decision- makers which ranged in publication date from 2008 to 2018.
need an evidence base upon which to provide policy with re-
spect to training, resources, and in-theatre decision-making.
The purpose of this document is to summarize the available Endotracheal Intubation
prehospital combat airway literature in order to better inform Thirteen studies reported on endotracheal intubation. Seven
mission planning and decision-making. from the war in Afghanistan, three from the war in Iraq, two

*Correspondence to shane.smith@lhsc.on.ca
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1 Shane Smith and Richard Hilsden are affiliated with the Royal Canadian Medical Service, Ottawa, ON, Canada and the Department of Surgery,
University of Western Ontario, London, ON, Canada. Bethann Meunier is affiliated with the Royal Canadian Medical Service, Ottawa, ON,
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Canada and with the Department of Anesthesia and Perioperative Medicine, Queen’s University, Kingston, ON, Canada. Michael Liu is affiliated
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with the Royal Canadian Medical Service, Ottawa, ON, Canada. Ian Ball is affiliated with the Royal Canadian Medical Service, Ottawa, ON,
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Canada, and the Departments of Medicine, Epidemiology and Biostatistics at the University of Western Ontario, London, ON, Canada.
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