Controversies in out-of-hospital emergency airway control: esophageal obstruction or endotracheal intubation?

Maintaining an unobstructed airway and providing adequate oxygenation and CO2 elimination, by artificial means if necessary, are among the highest priorities in all life-threatening circumstances. How this goal can best be met in the prehospital setting has become a controversial issue. The esophageal obturator airway (EOA) frequently is used in the prehospital setting, but its use and effectiveness recently have been criticized. A critical review of available literature reveals two areas of concern: 1) many clinical studies do not address prehospital airway management, and 2) the EOA has only one advantage over mask techniques for artificial ventilation, ie, it reduces the likelihood of aspiration of gastric contents. This advantage was the only one postulated by initial investigators. Many perceived EOA problems are due to poor mask fit and can be rectified. Although endotracheal intubation is the accepted standard for airway management in the apneic patient, its limitations in the prehospital setting are many. These utilization problems and complications remain undefined and must be addressed.