Effective airway management is essential during out-of-hospital cardiac arrest (OHCA) to ensure adequate ventilation and oxygenation. Advanced airway techniques, including the use of a supraglottic airway device (SAD) or endotracheal tube (ETT), typically follow initial bag-valve-mask (BVM) ventilation, with emergency front-of-neck access reserved as a last-resort option. Over time, and particularly during the COVID-19 pandemic, EMS airway management protocols have evolved. This study aimed to evaluate how these protocol changes affected airway management practices and the success rates of different techniques. We performed an observational analysis using data from the ARREST registry spanning 2019–2023. All adult OHCA patients receiving resuscitation from EMS were included, while cases involving helicopter emergency medical services were excluded. Trends in the use of airway devices during resuscitation and their first-pass success rates were analyzed. The proportion of cases in which an SAD was used increased, while ETT usage declined. Specifically, SADs were used in 59% of cases (95% CI: 57–60%), ETTs in 21% (95% CI: 19–22%), and BVM alone in 14% (95% CI: 13–15%). First-pass success for ETT placement improved from 53% to 68%, whereas SAD first-pass success remained consistently high at 93%. During CPR performed by ambulance nurses, the use of SADs rose and ETT use declined. Although ETT first-pass success improved, it remained below guideline-recommended standards for prehospital intubation. SAD placement demonstrated high first-pass success, supporting current Dutch EMS guidelines that prioritize SADs as the primary advanced airway device during resuscitation. Nonetheless, further training and skill development in intubation are necessary for selected OHCA patients.
