Supraglottic Device
An advanced airway device that is inserted into the upper airway above the vocal cords, providing a secured airway without requiring direct visualization of the trachea, used as a faster alternative to endotracheal intubation in many tactical and emergency settings.
In the Field
The supraglottic airway is what advanced field providers reach for when an unconscious patient needs more airway support than an NPA can provide. The two most common in EMS and tactical settings, the King LT and the i-gel, can be placed in seconds without the laryngoscopy and direct visualization that endotracheal intubation requires. They have largely replaced endotracheal intubation in many prehospital settings because they are faster, easier, and produce comparable outcomes for most field scenarios. For aid bag specifications, supraglottic device capability is one of the markers of provider-level kits.
Common Mistake
Continuing to specify endotracheal intubation as the primary advanced airway intervention when supraglottic devices have largely replaced intubation in prehospital practice for most scenarios.
Technical Detail
A supraglottic airway device (SGA) is an advanced airway device that is inserted into the upper airway and seated above (supra) the glottis (the vocal cords and laryngeal opening), providing a secured airway without requiring direct visualization of the trachea. SGAs have become the dominant advanced airway in prehospital and many emergency department settings, replacing endotracheal intubation as the primary advanced airway in many protocols.
How they work. Supraglottic devices are inserted blindly through the mouth into the pharynx. They are designed so that when properly seated, the distal end sits in the upper esophagus or hypopharynx, with the device occluding the esophagus and creating a seal that directs ventilation through the laryngeal opening into the trachea. The device incorporates one or more inflatable cuffs or pre-formed seals that conform to the upper airway anatomy.
Common supraglottic devices in tactical and emergency medicine:
King LT (Laryngeal Tube). A double-lumen tube with two inflatable cuffs (one in the esophagus, one in the pharynx) that seal the airway above and below the laryngeal opening. Single inflation port inflates both cuffs simultaneously. Widely used in EMS and tactical paramedic services.
i-gel. A single-lumen device with a pre-formed gel cuff that conforms to the upper airway anatomy without requiring inflation. The cuff softens at body temperature for an improved seal. Faster insertion than cuffed devices because no inflation step is required. Increasingly common in EMS.
LMA (Laryngeal Mask Airway). The original supraglottic device, with a single inflatable cuff that seats around the laryngeal opening. Used extensively in operating rooms and increasingly in prehospital practice.
Combitube (esophageal-tracheal). An older design with two cuffs and two ventilation ports, designed to function whether placed in the esophagus or trachea. Largely superseded by simpler King LT and i-gel designs.
Multiple other devices exist with various design features. Selection is typically driven by agency protocol, training, and provider preference within the available range.
Why supraglottic devices replaced intubation. Endotracheal intubation requires:
Direct visualization of the vocal cords using a laryngoscope.
Maintenance of airway alignment during the procedure.
Skilled insertion of an endotracheal tube through the cords.
Confirmation of placement.
In the tactical or prehospital environment, intubation has documented challenges:
Difficult airway anatomy. Trauma, obesity, and anatomic variation can make laryngoscopy difficult.
Limited visualization. Blood, vomit, and tactical conditions (low light, restricted positioning) impair the laryngoscopy view.
Time required. Even skilled providers require minutes for successful intubation in difficult conditions.
Procedural failure rate. Intubation failure in field conditions is well-documented, with consequences including misplaced tubes, esophageal intubation, and prolonged hypoxia during repeated attempts.
Skill maintenance. Intubation is a perishable skill requiring frequent practice. Many EMS systems do not produce enough opportunities for individual paramedics to maintain proficiency.
Supraglottic devices address most of these challenges. They can be inserted blindly in seconds, do not require direct visualization, have lower procedural failure rates in inexperienced or out-of-practice providers, and produce comparable patient outcomes for most scenarios.
When intubation remains preferred. Endotracheal intubation retains advantages in specific scenarios:
Definitive airway protection in patients with active vomiting or airway contamination.
Long-term ventilator management.
Specific clinical situations where the cuffed endotracheal tube provides advantages over the supraglottic seal.
Hospital and operating room settings where the conditions support reliable intubation.
In tactical and most prehospital settings, supraglottic devices have become the primary advanced airway, with intubation reserved for scenarios where it provides specific advantages.
Indications. SGAs are indicated for:
Unconscious patients without intact gag reflex requiring advanced airway support.
Patients in cardiac arrest requiring secured airway during resuscitation.
Patients with depressed level of consciousness from trauma, overdose, or other cause.
Failed bag-mask ventilation requiring escalation.
Anticipated need for prolonged ventilation during transport.
Contraindications. Relative contraindications include:
Intact gag reflex (the device is poorly tolerated and can cause vomiting and aspiration).
Caustic ingestion (the device may worsen esophageal injury).
Specific anatomic concerns (large airway masses, severe distortion).
Provider scope. Supraglottic device placement is a provider-level skill, taught at:
Paramedic level (formal training).
TCCC CLS and higher levels (military).
TECC provider levels (civilian).
Tactical paramedic and SWAT medic programs.
State EMS scope of practice rules and service medical director protocols govern when these devices may be used in civilian practice.
Aid bag specifications. SGAs are standard contents of:
Tactical paramedic and SWAT medic aid bags.
ALS-level EMS equipment.
Air medical and critical care transport units.
Advanced military combat medic kits.
They are not contents of basic IFAKs, where the airway adjuncts are typically limited to NPA and OPA.
Procurement implications. Supraglottic device capability is reflected in:
Device selection (King LT, i-gel, or other) based on agency standardization, protocol, and training.
Multiple sizes carried for different patient populations (adult and pediatric).
Insertion supplies including suction capability for blood and vomit.
Confirmation equipment (capnography is standard in modern advanced airway protocols).
Training, with periodic skill maintenance practice.
Service medical director protocols authorizing use within scope of practice.
The shift from intubation to supraglottic devices has changed the equipment, training, and protocol landscape of advanced prehospital airway management substantially over the past decade.
How they work. Supraglottic devices are inserted blindly through the mouth into the pharynx. They are designed so that when properly seated, the distal end sits in the upper esophagus or hypopharynx, with the device occluding the esophagus and creating a seal that directs ventilation through the laryngeal opening into the trachea. The device incorporates one or more inflatable cuffs or pre-formed seals that conform to the upper airway anatomy.
Common supraglottic devices in tactical and emergency medicine:
King LT (Laryngeal Tube). A double-lumen tube with two inflatable cuffs (one in the esophagus, one in the pharynx) that seal the airway above and below the laryngeal opening. Single inflation port inflates both cuffs simultaneously. Widely used in EMS and tactical paramedic services.
i-gel. A single-lumen device with a pre-formed gel cuff that conforms to the upper airway anatomy without requiring inflation. The cuff softens at body temperature for an improved seal. Faster insertion than cuffed devices because no inflation step is required. Increasingly common in EMS.
LMA (Laryngeal Mask Airway). The original supraglottic device, with a single inflatable cuff that seats around the laryngeal opening. Used extensively in operating rooms and increasingly in prehospital practice.
Combitube (esophageal-tracheal). An older design with two cuffs and two ventilation ports, designed to function whether placed in the esophagus or trachea. Largely superseded by simpler King LT and i-gel designs.
Multiple other devices exist with various design features. Selection is typically driven by agency protocol, training, and provider preference within the available range.
Why supraglottic devices replaced intubation. Endotracheal intubation requires:
Direct visualization of the vocal cords using a laryngoscope.
Maintenance of airway alignment during the procedure.
Skilled insertion of an endotracheal tube through the cords.
Confirmation of placement.
In the tactical or prehospital environment, intubation has documented challenges:
Difficult airway anatomy. Trauma, obesity, and anatomic variation can make laryngoscopy difficult.
Limited visualization. Blood, vomit, and tactical conditions (low light, restricted positioning) impair the laryngoscopy view.
Time required. Even skilled providers require minutes for successful intubation in difficult conditions.
Procedural failure rate. Intubation failure in field conditions is well-documented, with consequences including misplaced tubes, esophageal intubation, and prolonged hypoxia during repeated attempts.
Skill maintenance. Intubation is a perishable skill requiring frequent practice. Many EMS systems do not produce enough opportunities for individual paramedics to maintain proficiency.
Supraglottic devices address most of these challenges. They can be inserted blindly in seconds, do not require direct visualization, have lower procedural failure rates in inexperienced or out-of-practice providers, and produce comparable patient outcomes for most scenarios.
When intubation remains preferred. Endotracheal intubation retains advantages in specific scenarios:
Definitive airway protection in patients with active vomiting or airway contamination.
Long-term ventilator management.
Specific clinical situations where the cuffed endotracheal tube provides advantages over the supraglottic seal.
Hospital and operating room settings where the conditions support reliable intubation.
In tactical and most prehospital settings, supraglottic devices have become the primary advanced airway, with intubation reserved for scenarios where it provides specific advantages.
Indications. SGAs are indicated for:
Unconscious patients without intact gag reflex requiring advanced airway support.
Patients in cardiac arrest requiring secured airway during resuscitation.
Patients with depressed level of consciousness from trauma, overdose, or other cause.
Failed bag-mask ventilation requiring escalation.
Anticipated need for prolonged ventilation during transport.
Contraindications. Relative contraindications include:
Intact gag reflex (the device is poorly tolerated and can cause vomiting and aspiration).
Caustic ingestion (the device may worsen esophageal injury).
Specific anatomic concerns (large airway masses, severe distortion).
Provider scope. Supraglottic device placement is a provider-level skill, taught at:
Paramedic level (formal training).
TCCC CLS and higher levels (military).
TECC provider levels (civilian).
Tactical paramedic and SWAT medic programs.
State EMS scope of practice rules and service medical director protocols govern when these devices may be used in civilian practice.
Aid bag specifications. SGAs are standard contents of:
Tactical paramedic and SWAT medic aid bags.
ALS-level EMS equipment.
Air medical and critical care transport units.
Advanced military combat medic kits.
They are not contents of basic IFAKs, where the airway adjuncts are typically limited to NPA and OPA.
Procurement implications. Supraglottic device capability is reflected in:
Device selection (King LT, i-gel, or other) based on agency standardization, protocol, and training.
Multiple sizes carried for different patient populations (adult and pediatric).
Insertion supplies including suction capability for blood and vomit.
Confirmation equipment (capnography is standard in modern advanced airway protocols).
Training, with periodic skill maintenance practice.
Service medical director protocols authorizing use within scope of practice.
The shift from intubation to supraglottic devices has changed the equipment, training, and protocol landscape of advanced prehospital airway management substantially over the past decade.