FOI 26-008 ETI v SGA Research
Freedom of Information Request
- Reference
- FOI 26-008 ETI v SGA Research
- Request Date
- 04 Jan 2026
- Response Date
- 23 Jan 2026
- Information Requested
I am writing to request information under the Freedom of Information (Scotland) Act 2002, relating to the response issued by the Scottish Ambulance Service (SAS) to FOI reference 25-554, specifically the unsolicited “Background” section of that response, which set out a number of factual claims regarding endotracheal intubation (ETI) and supraglottic airway (SGA) use in out-of-hospital cardiac arrest. That paragraph states, among other things, that current evidence shows SGAs to be safer, quicker, and more effective; that SGAs improve return of spontaneous circulation; that ETI carries significant risks and is harder to maintain competency in due to infrequent use; and that most UK ambulance services have already made this change without adverse outcomes, with SAS aligning to national best practice. For the avoidance of doubt, this FOI does not ask the SAS to justify or defend its policy position, nor to create renewed analysis or commentary. It seeks only to identify what information was relied upon when making the factual statements included in the response. Please therefore provide the following information, insofar as it is held:
- Evidence relied uponForeach of the following claims made in the FOI 25-554 response, please identify the peer-reviewed research, systematic reviews, registry analyses, or published guidelines that were relied upon when drafting that paragraph:
- a) That modern supraglottic airway devices are safer than ETI in out-of-hospital cardiac arrest
- b) That SGAs are more effective than ETI in out-of-hospital cardiac arrest
- c) That SGA use is associated with improved return of spontaneous circulation
- d) That ETI carries significant patient safety risks in this context
- e) That ETI competency is harder tomaintaindue to infrequent use
- f) That changes made by other UK ambulance services have occurred without adverse outcomes
- g) That the SAS position reflects national best practice
- Competency maintenance comparisonInrelation to the claim that ETI competency is harder to maintain due to infrequent use, please identify whether any evidence was considered that compared ETI competency decay or skill maintenance requirements with other low-frequency, high-risk pre-hospital interventions (e.g. direct laryngoscopy, needle or surgical cricothyrotomy, or chest decompression). If such evidence was considered, please identify it. If no comparative evidence was considered, please confirm this.
- Currency of evidenceForeach source identified above, please provide:
- a) The publication year
- b) Whether it is peer-reviewed
- c) Whether it was published within the last five years, and if not, whether more recent evidence was considered
- Guidelines and consensus statements Pleaseidentifyany national or international clinical guidelines or consensus statements considered when making the claims above, including (but not limited to) documents from ILCOR, the European Resuscitation Council, or UK national bodies, and confirm which specific sections were relied upon.
- Internal records of consideration Please confirm whether SAS holds any internal recordsevidencingconsideration of the above evidence, such as briefing papers, clinical reviews, meeting minutes, or correspondence, and identify the type of record held and its date.
- Response
Q1 - The Scottish Ambulance Service (SAS) bulletin on Advanced Airway Management cites several published studies, systematic reviews and national clinical guidelines when discussing airway techniques used during out‑of‑hospital cardiac arrest. The document draws mainly on evidence comparing endotracheal intubation (ETI) with supraglottic airway devices (SGAs), including findings from randomised controlled trials, meta‑analyses, and established UK guidelines.
Under Section 25 of FOISA, some of this information is already publicly available through the references cited in the bulletin. We have therefore listed below the evidence exactly as recorded.
Claim
Cited Evidence
a) That modern supraglottic airway devices are safer than ETI in out-of-hospital cardiac arrest
Forestell et al. 2023; Benger et al. 2022 (AIRWAYS-2); Katz & Falk 2001; Benoit et al. 2015
b) That SGAs are more effective than ETI in out-of-hospital cardiac arrest
Forestell et al. 2023; Benger et al. 2022
c) That SGA use is associated with improved return of spontaneous circulation
Forestell et al. 2023; Benger et al. 2022
d) That ETI carries significant patient safety risks in this context
Katz & Falk 2001; Benoit et al. 2015; Mitchell et al. 2014
e) That ETI competency is harder to maintain due to infrequent use
College of Paramedics Consensus Statement 2018; Scottish HEI Consensus (Appendix 2)
f) That changes made by other UK ambulance services have occurred without adverse outcomes
Appendix 1 – Survey of UK ambulance trusts
g) That the SAS position reflects national best practice
JRCALC guidance; Resuscitation Council UK 2021; College of Paramedics 2018; Appendix 1 UK-wide survey
Q2 - Other clinical skills were not within the scope of this review. It should be noted that since the change in practice in May 2025, ETI skill maintenance is explicitly addressed by the Resuscitation Council (UK) in their publication: Advanced Life Support (9th Edition) published November 2025 which states:
"While tracheal intubation has traditionally been regarded as the gold standard for airway management, there is limited evidence to support its benefit over other airway interventions in cardiac arrest. In the out-of-hospital settings, tracheal intubations should be reserved for specialist providers operating within a defined governance framework and competence standard. Training on manikins or a small number of successful intubation attempts in the operating theatre does not provide adequate skill for unsupervised tracheal intubation"
Q3 – Under the Freedom of Information Scotland Act 2002 (FOISA_ the Scottish Ambulance Service can only provide information that is held. We have therefore extracted the publication year where it is explicitly recorded in the bulletin, identified whether each source is a journal article (i.e., typically peer‑reviewed), guideline, or survey/consensus, and indicated whether it falls within the last five years. We have applied section 17 of FOISA to the sections where this information is not held by. Further details confirming peer‑review status of journals are otherwise accessible from publishers under Section 25.
Source
Publication year (as recorded)
Peer‑reviewed?
Within last 5 years
Forestell et al. – Critical Care Medicine (Systematic review & meta-analysis of RCTs)
2023
Section 17
Yes
Benger et al. (AIRWAYS-2) – Health Technology Assessment
2022
Section 17
Yes
Bartos et al. – Resuscitation
2023
Section 17
Yes
Benoit, Prince & Wang – Resuscitation
2015
Section 17
No
Katz & Falk – Annals of Emergency Medicine
2001
Section 17
No
Mitchell, Short & Clegg – Emergency Medicine Journal
2014
Section 17
No
College of Paramedics – Intubation Consensus Statement
2018
Professional body consensus (not a peer‑reviewed journal article)
No
Scottish HEI “Consensus Approach to Advanced Airway Education for Undergraduate Paramedics in Scotland” (Appendix 2)
Section 17
Educational consensus (not a peer‑reviewed journal article)
Section 17
JRCALC guidance (referenced in Appendix 2 narrative)
Section 17
Published clinical guidance (not a peer‑reviewed journal article)
Not determinable from bulletin
Resuscitation Council (UK) – Advanced Life Support Guidelines
2021
Guideline (not a peer‑reviewed journal article)
Yes
Appendix 1 – Survey of ETI practice by UK ambulance trusts (“All information… updated in 2023”)
2023
Service survey/compiled returns (not peer‑reviewed)
Yes
Q4 and Q5 -
Please see the attached paper. Further updated published guidance is also available via the European Resuscitation Council and published in Resuscitation in Nov 2025 - GL2025 attached
This publication provides ILCOR most up to date reviews and within it states: If an advanced airway is used, we suggest an SGA for adults with OHCA in settings with a low tracheal intubation success rate. This is consistent with SAS stance.
- Response Documents
