In 2007, a helicopter emergency medical services crew was in flight with a polytrauma patient who was deteriorating. The airway appeared difficult. The crew chose to sedate, paralyze, and place a laryngeal mask. No preliminary attempt at direct laryngoscopy. There was no failed intubation to rescue, because there had been no intubation.
Darren Braude and Michael Richards published the case in Prehospital Emergency Care and gave the maneuver a name: Rapid Sequence Airway. Nineteen years later, the technique has a small body of evidence, only one fully published protocol, a national trend line, and a persistent reputation problem. It continues to be read as the thing you do when you're unable to intubate. That's not what the data describe.
Four Techniques, One Word
Much of the international debate about RSA consists of people discussing different procedures using the same vocabulary. It's worth establishing the terms.
The NAEMSP places RSA within a family it calls drug-assisted airway management. Sedation-assisted intubation uses sedative alone. Delayed sequence intubation administers the sedative first and delays the paralytic, buying time to preoxygenate. Rapid sequence intubation gives both, then a tube. Rapid sequence airway gives both, then a supraglottic device, as a primary airway and not as a fallback.
Then there's the British variant, which is not the same thing at all. Pharmacologically assisted laryngeal mask insertion, PALM, uses induction agents without neuromuscular blockade. It's in the indications of the Faculty of Pre-Hospital Care, and the 2013 consensus document was not endorsed by the Royal College of Anaesthetists. The Faculty's formulation is narrow and defensive: hypoxic patient in whom RSI is not possible and basic maneuvers have been exhausted, rescue technique and not primary strategy, checklist-driven, second-generation device at minimum, mandatory capnography, only in trained hands.
The distinction weighs more than it appears. PALM leaves the patient with residual tone and an indefinite interval before a definitive airway. RSA abolishes reflexes and commits. They carry different risks and answer different questions, and when work on one is used to argue about the other, the discussion ceases to be clinical.
What the Evidence Actually Says
The largest prehospital case series remains Braude's quality registry, published in 2020: 68 adult and pediatric patients, one ground station and one air station, from 2005 to 2017. Success, defined as the ability to ventilate adequately after placement, was achieved in 64 cases, 94 percent. First-pass success was 88 percent and 98 percent of airways were secured within two attempts. Seventy-one percent of these patients were in cervical immobilization and one-fifth of the procedures occurred inside an aircraft, meaning the case series was not enriched with easy airways.
One number in that work deserves to be read twice. The device remained in place before hospital arrival for a time ranging from 5 to 102 minutes, with a mean of 34 and a half.
In the emergency department, the practice exists, though quietly. Lee, Braude, and the Hennepin group described ten years of RSA with intubating laryngeal mask as the first definitive device, arguing that in selected patients there are real advantages to choosing a supraglottic device instead of laryngoscopy, and not after it. The counterpoint came from the National Emergency Airway Registry in 2023: the use of extraglottic devices in emergency airway management is rare. The technique is available and the culture doesn't want it.
The trend line, however, is moving. A five-year analysis of a U.S. national database, published in January 2026, examined ALS interventions in non-arrest patients, 36,058 after exclusions. Attempts with a supraglottic device as the first device increased from 3.5 to 8.7 percent of invasive airway procedures. The i-gel rose from 42 to 82 percent of devices used, the King LTS-D fell from 50 to 14. And in 74 percent of these interventions, a neuromuscular blocker was used.
This last datum dismantles the received narrative. If three-quarters of primary supraglottic attempts include a paralytic, then whoever is doing this procedure is not a provider lacking RSI pharmacology. They have the drugs, they have the authorization, and they choose a different device.
Aspiration, the Objection That Hasn't Held
The standard argument against RSA is that a cuffed tube in the trachea protects the lungs and a supraglottic device doesn't.
The evidence supporting this proposition is more subtle than the confidence with which it's stated. Steuerwald and Braude compared aspiration rates between prehospital patients ultimately managed with an extraglottic device and intubated patients, using radiological evidence within 48 hours as the endpoint. Usable data for 67 and 94 patients respectively, difference not statistically significant. The authors were cautious, noting that the assumption of substantially greater protection by the tube has historically rested on expert consensus rather than measurement, and that their own numbers require prospective confirmation.
In Braude's RSA case series, radiological aspiration appeared in 4 of 46 patients with available imaging, 8.7 percent, in a cohort selected for difficult airway.
On outcome, rather than aspiration, the strongest signal comes from the German trauma registry. 10,408 patients, 92.5 percent intubated and 7.5 percent managed with extraglottic device, in-hospital mortality 33 percent versus 30.7, adjusted odds ratio for the intubated group 1.09 with confidence intervals crossing unity. No difference. The honest caveat is that injury severity was greater in the intubated group, so selection works in two opposite directions simultaneously and neither strong conclusion is available from these data.
None of this establishes that a supraglottic device is equivalent to a tube. It establishes that the safety distance between the two is wider than the evidence distance.
How It's Actually Done
Only one RSA protocol has been published in full, and this makes the Alachua County Fire Rescue field report the most useful operational document in the literature. It's also useful because it documents its own mistakes.
The original sequence called for ketamine 1-2 mg/kg, then up to two attempts at supraglottic device placement. In case of failure, rocuronium 1.5 mg/kg and a third attempt. Only after that, intubation or surgical airway, if bag-valve ventilation didn't support the patient. Primary intubation was reserved for extensive burns, severe anaphylaxis, and facial or cervical trauma where edema or bleeding above the cords argued against the supraglottic device.
Each attempt required a capnographic waveform for confirmation. Failure was defined by four observable criteria: difficulty oxygenating or ventilating, significant air leak, dyssynchrony with ventilation, absence of an appropriate ETCO2 waveform. That definition is the best-written sentence in the protocol, because it's the part a crew can apply without interpreting.
Then, in practice, two things happened, and both are instructive.
The first concerns the paralytic. The designers had deliberately delayed rocuronium to avoid prolonged paralysis and shorten the apneic window. In about half the cases, providers administered sedative and paralytic together before the first attempt, and complication rates were not different. The system ended up modifying the protocol to allow it, and replaced rocuronium with succinylcholine so that no patient could remain paralyzed without adequate sedation. The reason that step hadn't been taken before wasn't pharmacological. It was that the ambulances didn't have refrigeration.
The second concerns sedation. Ketamine was to be repeated every 15 minutes at 0.5 mg/kg. Despite specific training on this point, redosing during transport was rare. The mean transport time in that county was 14 minutes and 55 seconds, so the omission mostly didn't bite. The authors explicitly state that surveillance of sedative and analgesic redosing, when a long-acting paralytic has been administered, becomes critical in systems with transport times longer than theirs.
The results, in themselves, were clear. Three cases required a second attempt, none a third, no device failed to the point of requiring escalation. In the 27 percent of cases where a provider chose intubation as the first device in violation of the protocol, first-pass success was 44 percent, versus 87.5 when the protocol was followed.
The last datum is the one worth pausing on. Among patients with available hospital documentation, every supraglottic device placed in the prehospital setting was replaced in the emergency department, typically by video laryngoscopy, and in all but one case the replacement occurred for physician preference alone. None was replaced for suspected dislodgement, because in no case had capnography suggested it. The devices were working. They were removed because the tube is what the room expects.
What No One Has Studied
An honest article on this topic must mark its own boundaries, so here are the points where the literature is silent rather than reassuring.
There are no recommended peak pressure limits for mechanical ventilation through a supraglottic device in the field. There is no PEEP strategy: Alachua leaves it to provider discretion, which is a polite way of saying no one knows. There is no maintenance paralysis protocol beyond the first twenty minutes. Use of the gastric channel for decompression is listed among the advantages of second-generation devices, and its actual benefit is described even by its proponents as questionable. And there is no evidence on supraglottic airway management beyond one hour of ground transport in mountain environments.
Some of these gaps may close. A 2026 study on manual versus automated ventilation through i-gel during short-range helicopter operations suggests the ventilation question is finally being asked, and it's worth reading when the full text becomes available.
What exists at the opposite extreme is anecdote, and it's remarkable anecdote. Braude reported an LMA-Supreme used as a primary airway for nine hours in a polytrauma patient. The i-gel manufacturer's instructions allow four hours in place. Against this, the durations recorded in all published case series are short, because the systems that generated those data have short transports.
The Question a Physician-Staffed System Must Ask
Every strand of this literature grew in systems where the initial problem was that the clinician on scene could not or might not intubate. From that premise the conclusion follows easily, and it is the conclusion most people have absorbed: RSA is a workaround for missing capability.
My system poses the question the other way round. Prehospital rapid sequence intubation is available. So the interesting question is not what a crew does without it. The question is whether there are situations in which a clinician who can intubate should deliberately choose not to, and what the answers are worth.
Four candidates suggest themselves, and none of them has been studied. Restricted access to the patient, where the anatomy of the scene rather than the anatomy of the airway governs the choice: entrapment, a rock face, an avalanche debris field. A single advanced provider carrying competing tasks, where the cost of a procedure is measured in what stops happening while it is performed. Transport times long enough that the hundred and two minutes in Braude's series stops being an outlier and becomes a Tuesday. And crews of nurses and technicians operating under remote physician oversight, where RSA is not a technique an individual selects but a decision a system authorises, monitors, and audits.
That fourth case is the one I find least discussed and most consequential, because it changes the object of the question. Whether a supraglottic device is an acceptable primary airway is a clinical question. Whether a dispatch physician should be able to authorise one, on the basis of what information, with what monitoring returned down the line, is a governance question, and governance questions are where prehospital systems actually differ from one another.
Which returns to the Alachua finding about exchange. The devices were ventilating. Capnography confirmed it. They were replaced anyway, on preference. Somewhere in that gap between what the monitor showed and what the room expected is the real subject of this whole literature, and it is not about airways.
References
- Braude D, Richards M. Rapid Sequence Airway (RSA), a novel approach to prehospital airway management. Prehosp Emerg Care. 2007;11(2):250-252.
- Braude D, Dixon D, Torres M, Martinez JP, O'Brien S, Bajema T. Brief research report: prehospital rapid sequence airway. Prehosp Emerg Care. 2021;25(4):583-587.
- Braude D, Southard A, Bajema T, Sims E, Martinez J. Rapid sequence airway using the LMA-Supreme as a primary airway for 9 h in a multi-system trauma patient. Resuscitation. 2010;81(9):1217.
- Southard A, Braude D, Swenson K, Sullivan A. Using rapid sequence airway to facilitate preoxygenation and gastric decompression prior to emergent intubation. J Anesth Clin Res. 2010;1:113.
- Lee DH, Stang J, Reardon RF, Martel ML, Driver BE, Braude DA. Rapid sequence airway with the intubating laryngeal mask in the emergency department. J Emerg Med. 2021;61(5):550-557.
- Johnston BJ, Leung AK, Hwang CW, et al. Medication-facilitated advanced airway management with first-line use of a supraglottic device, a one-year quality assurance review. Prehosp Disaster Med. 2022;37(4):561-565.
- Knack S, Robinson A, et al. Trends in prehospital first-attempt use of supraglottic airways in non-cardiac arrest patients: a descriptive study. Prehosp Emerg Care. Published online January 2026. doi:10.1080/10903127.2025.2593579
- Steuerwald MT, Braude DA, Petersen TR, Peterson K, Torres MA. Preliminary report: comparing aspiration rates between prehospital patients managed with extraglottic airway devices and endotracheal intubation. Air Med J. 2018;37(4):240-243.
- Weigeldt M, Schulz-Drost S, Stengel D, Lefering R, Treskatsch S, Berger C. In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients, a cohort study from the TraumaRegister DGU. Eur J Trauma Emerg Surg. 2024;50(4):1637-1647.
- Moss R, Porter K, Greaves I. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J. 2013;30(12):1073-1075.
- Baldino KT, Jacobs M, March JA, Peterson TD, et al. Prehospital supraglottic airways: an NAEMSP position statement and resource document. Prehosp Emerg Care. 2022;26(sup1).
- April MD, Driver B, Schauer SG, et al. Extraglottic device use is rare during emergency airway management: a National Emergency Airway Registry (NEAR) study. Am J Emerg Med. 2023;72:95-100.
- Nickson C. Rapid sequence airway (RSA) and PALM. Life in the Fast Lane, Critical Care Compendium.
- Quilter WE, Hartridge TA, Katz J, et al. Manual versus automated ventilation with an i-gel airway during short-haul helicopter operations. Prehosp Emerg Care. 2026.
