Background: Emergency medical technicians (EMTs) and paramedics frequently manage airway and
oxygenation in the prehospital setting. However, advanced airway techniques and liberal oxygen delivery
may introduce safety risks (multiple attempts, misplacement, interruptions) while potential outcome benefits
vary by patient group. Objective: To synthesize evidence on the association between EMT prehospital
airway and oxygenation strategies and patient outcomes and safety events. Methods: We conducted a
PRISMA aligned systematic review of original human studies available in PubMed Central. We included
randomized and observational studies evaluating prehospital airway (endotracheal intubation, supraglottic
airways, airway process) and oxygenation strategies delivered by EMS personnel, reporting patient
outcomes and, or safety events. Outcomes of interest included survival (short term and discharge), neurologic outcome where available, ROSC, mortality, and procedure related complications. Results: Ten original studies were included, spanning out of hospital cardiac arrest, trauma, TBI, and mixed EMS airway cohorts. In a cluster crossover randomized trial of adults with out of hospital cardiac arrest, an initial
laryngeal tube (LT) strategy improved 72 hour survival compared with endotracheal intubation (ETI) and
had higher initial airway success, with similar key adverse events. Large observational EMS datasets
consistently linked airway performance and operator experience to outcomes, with improved survival in
cardiac arrest and medical non arrest when ETI was performed by more experienced rescuers. In traumatic
out of hospital cardiac arrest, advanced airway management improved ROSC on hospital arrival but not
survival to discharge. For severe TBI without hypoxia, low flow oxygen was associated with lower mortality
while high flow oxygen in patients with high saturations showed worse associations. Conclusion:
Prehospital airway and oxygenation management by EMS personnel is high impact but context dependent.
Supraglottic first strategies may offer pragmatic advantages during cardiac arrest, while ETI outcomes
appear sensitive to provider experience and system quality. Oxygen should be titrated to avoid both hypoxia
and hyperoxia, particularly in TBI.