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Standardised data reporting from pre-hospital advanced airway management – a nominal group technique update of the Utstein-style airway template



Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset.


We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process.


The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described.


Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.

Trial registration

The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260).


Pre-hospital advanced airway management (PHAAM) with the control of oxygenation and ventilation is vital in the management of critically ill or injured patients in the field and may contribute to better outcomes [1,2,3]. Results from research on PHAAM are challenged by heterogeneity in provider competence, airway techniques, and the quality of data collected in many airway studies [4]. To improve pre-hospital critical care and to develop evidence-based guidelines, research based on standardised high-quality data is important [5, 6]. Using a common and uniform set of data definitions may be the first step in such a process [7].

In pre-hospital critical care research, there has been an acceptance and tradition for using structured consensus methods to evaluate interventions, to develop guidelines, and for educational and research purposes [8, 9]. Templates for documenting and reporting of standardised data have been developed by similar methodology for out-of-hospital cardiac arrest, paediatric advanced life support, in-hospital cardiac arrest resuscitation, major incidents and disaster management, laboratory cardiopulmonary research, major trauma, emergency medical dispatch, physician staffed emergency medical services and drownings [10,11,12,13,14,15,16,17,18,19]. Developments in airway management devices, airway management strategies and training, along with patient safety issues; require that such templates are updated on a regular basis like clinical guidelines and recommendations [20].

An Utstein-style airway template was published in 2009 by an international airway expert group [21]. The feasibility of collecting standardised airway data across different patient populations and international emergency medical services (EMS) have been described [22]. The aim of this study was to update and revise the Utstein-style template for the reporting of PHAAM data, using a nominal group technique (mNGT) with international experts to identify which data variables would be most important to document today.


Study design

The revision of the Utstein-style airway template was performed using a modified nominal group technique (mNGT) consensus process, which has previously proven useful in the development of templates and guidelines for pre-hospital critical care [9, 14].

Pre-hospital advanced airway management

In the original template, advanced airway management was defined as the attempted insertion of an advanced airway adjunct or the administration of ventilatory assistance, in this context being “any airway management beyond manual opening of the airway and the use of simple adjuncts, such as an oropharyngeal airway”. This type of management includes the use of a supraglottic airway device (SAD), tracheal intubation (TI), or emergency front of neck access (eFONA).

Data variable

A data variable should be clearly defined to avoid misinterpretation. Data points should be simple to register and possible to integrate into existing registries [21]. This requires a data variable dictionary containing information on data number, name, type of data, categories or values and definition of data variable [14].

Group of experts

The recruited experts were clinicians with leadership experience from pre-hospital critical care, had made substantial contributions to airway management research or airway management guidelines, or were considered experts in the field of PHAAM. They were recruited from networks such as European Pre-hospital Research Alliance (EUPHOREA) and the European Airway Management Society (EAMS). The experts were invited by individual email and were not aware of the composition of the group until the final consensus meeting.

The modified nominal group process

The mNGT is a systematic qualitative method involving questionnaires in repeated rounds with a final meeting aimed at consensus [9]. Our mNGT included three email rounds with questionnaires and answers (QA), and a one-day consensus meeting for plenary discussions. A fourth email round was included after the meeting for minor adjustments or comments. The results from each round were used to guide the development of the questionnaires for the following round. A third party distributed and managed the responses from the experts in individual emails and anonymised the answers. The mNGT was run from February to August 2017. The final dataset was forwarded to the experts for approval.

First email round

An Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA) with the original template variables was sent to the experts (Additional file 1: Table S1). The experts were instructed to rate each variable on a 5-point Likert scale (from 1 = “totally disagree” to 5 = “totally agree”) according to how important the variable was considered to be for PHAAM and to indicate whether the original variable should be changed. The experts were then requested to suggest between three and five new variables. Additional free-text comments were allowed. These comments were not distributed to the other experts but were used to revise the variables.

Second email round

The revised variables were organised in the original template sections, with the suggested new variables in the “optional variables section” (Additional file 2: Table S2). The experts were instructed to rank the most important variables within each section. Where relevant and for the ranked variables only, the experts indicated whether changes were warranted. Additional free-text comments were also possible in this round.

Third email round

The instructions for ranking and suggestions were similar to those of the previous round, with the revised variables now grouped in core-system, core-patient, core-post-intervention, or fixed-system sections (Additional file 3: Table S3).

The consensus meeting

The aim of the consensus meeting was to finalise the variable set and discuss items that had not been cleared during the first three rounds. The main results after the email rounds were presented, and the expert comments from the preceding rounds were used to guide the discussions. The experts agreed by consensus on the changes to the template structure or variables.


We measured expert commitment towards each variable as the number of times the individual variable was nominated by the experts. Within each section, the variables rated as “most important” received the highest score, and those rated as “least important” received the lowest score. If two variables scored equally, the variable with the highest number of individual nominations, compared to those with highest rating, was ranked higher.



Twenty-one experts were invited to join the mNGT-process, of whom sixteen participated in all email rounds. The experts were recruited from Australia, United States of America, and Europe. The level and type of airway experience, along with country of origin of the expert group, is described in Additional file 4. Of the experts who participated, eight attended the final consensus meeting, along with five members of the project steering group.

Definition of PHAAM

The expert group decided to keep the definition of advanced airway management unchanged from the original template, as the attempted insertion of an advanced airway adjunct or administration of ventilatory assistance”.

First email round

The experts made 127 unique suggestions for changes in variable names, categories or values in 28 (44%) of the original variables. After merging similar suggestions and variables, 15 variable names and 22 categories were revised. Fifteen new variables were added to the dataset before the second email round (Additional file 2: Table S2). This process is detailed in the flowchart (Fig. 1).

Fig. 1

Flowchart describing the modified nominal group technique. The original variables were modified or deleted, and new variables inserted according to the experts’ comments and suggestions at each stage. Similar suggestions and variables were merged

Second email round

The experts indicated that change was warranted for 24 (18%) variables and suggested 43 unique changes. Twenty-nine additional comments to improve the variables were submitted. After ranking and merging similar suggestions, 27 variables were cut, leaving 51 variables to be included in email round three. Following the experts’ suggestions, the optional section was removed, and its variables were distributed in the remaining sections (Additional file 3: Table S3).

Third email round

In this round, the experts indicated a need for change in the variable name, category or definition for 23 (45%) variables, and provided ten additional comments to improve the variables. The remaining variables were revised and formed the starting point for the discussions in the consensus meeting (Additional file 5: Table S4).

The consensus meeting

The experts discussed the remaining 41 variables and 10 “runner-up” variables. The experts agreed on a dataset including 32 operational variables with an additional six system variables that were identical across all missions, compared to 63 variables in the original template (Tables 1, 2, 3, 4). Of the original variables, only one variable (age) remained unchanged. Nineteen original variables were modified in terms of the variable name, category, definition or value, and the experts added 16 new variables to the revised dataset. The experts agreed on a new template structure with time, patient, airway management and system sections. The recording of PHAAM data was to cover the interval from the patient encounter on scene to when post-intervention ventilation was established, and survival to hospital (short-term survival).

Table 1 Final time variables
Table 2 Final patient variables
Table 3 Final airway management variables
Table 4 Final system variables


Main results

Using a modified nominal group process with international airway experts, supported by clinical study results with the original template described in the recent AIRPORT studies, we have revised the template for the reporting of standardised data from PHAAM [22, 23]. The updated dataset includes new data points that reflect risk factors for difficult PHAAM, the use of checklists and standard operating procedures (SOPs), strategies for pre-oxygenation, the use of drugs in PHAAM, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described in the Utstein-style airway template.

Time variables

Three time intervals are important for describing a pre-hospital response adequately: the response time, on-scene time, and patient transport time to the hospital. In comparing EMS or dispatch services across patient populations and services, these intervals are valuable for describing the EMS response, which is also closely linked to the efficiency of the dispatch process [24].

Patient variables

Patient age and sex should be included in any study population demographics [5]. We have previously shown a non-linear association between patient age and the first-attempt TI failure rates and that a significant age difference exists between trauma and non-trauma patients intubated by physician-staffed helicopter emergency medical services (HEMS), indicating that it is important to include age in a PHAAM dataset [22]. A sex difference has also previously been described in emergency airway management [25].

Category describes the dominating reason for the emergency treatment, while indication describes the dominating indication for the airway intervention itself. While the patient category is among the variables most consistently reported (86%) in airway studies, indication is less frequently reported (36%) [5]. Describing trauma cases, differentiating between blunt trauma and penetrating trauma may be important, as strategies for both airway management and haemorrhage control can differ between these groups [26]. Traumatic brain injury (TBI) is another major category where treatment options may differ, and airway management competence is linked to mortality in this group [27]. In non-trauma patients, the experts agreed that distinguishing between cardiac arrest; neurological emergencies; respiratory distress or breathing difficulties; intoxication; infection (including sepsis); and other medical emergencies may be important when describing PHAAM.

Airway assessment is an integral part of providing safe pre-hospital anaesthesia and advanced airway management. Patient risk factors for difficult bag-valve-mask (BVM) ventilation or TI were not included in the original template. Optimal patient positioning may maximise the chance of successful PHAAM [20]. And, the pre-hospital setting contains some unique external factors, which may influence access to the patient and hence airway management success [28, 29]. The expert panel agreed that such risk factors should be described in the dataset.

Key vital signs are commonly used to assess the physiological status of patients in many clinical settings [30]. The experts agreed that single values, not ranges of measurements, should be recorded in general. Agreeing on the necessity of an initial baseline measurement of the patient’s respiratory rate (RR), blood pressure, peripheral oxygen saturation (SPO2) and Glasgow coma score (GCS), the experts also found that recording the lowest value prior to and during the airway intervention was important. The recording of end-tidal carbon dioxide (ETCO2) after finalised PHAAM is important to confirm tube placement but may also be beneficial for optimising advanced life support (ALS) [31].

Airway management variables

The use of pre-TI checklists for PHAAM to reduce adverse events and improve patient safety is recommended [32]. However, a recent multicentre randomised trial of checklist use in rapid sequence intubation (RSI) found no reduction in complication rates compared to standard practice without checklists [33]. While experienced providers may rely on mental checklists, inexperienced providers may depend on written checklists in a challenge and response system. The experts agreed that the airway dataset should only document whether a written checklist is available on scene and whether the checklist was used.

The Difficult Airway Society recommends that pre-induction airway plans are briefed to the team and that failure of primary or secondary airway plans are clearly declared to facilitate control of the patients’ airways and to avoid complications [20]. Although a prediction of a difficult airway is not always reliable, a planned and verbalised pre-induction airway plan should be in place prior to an RSI [20, 34]. The experts agreed that recording whether PHAAM was successful as planned and documenting whether the final airway attempt failed were important.

There is evidence for an association between airway management skills and patient outcomes in PHAAM [27, 35]. Poorly performed airway management carries significant mortality and morbidity risks, and adequate training and experience is important for patient safety [35]. As success and complication rates are also associated with provider competence and experience, the experts found that recording the level and sequence of providers performing the actual airway interventions was necessary [36]. Specifying the sequence of providers may provide new knowledge of PHAAM, especially where primary airway management fails and an unanticipated difficult airway in the field must be handled. Furthermore, the results from airway studies are difficult to interpret and compare without such information. The total number of successful TIs the provider has performed in patients in hospital and in pre-hospital service may be regarded as a reasonable surrogate for total airway competence [37].

Patient pre-oxygenation is standard practice during any anaesthesia induction, aiming at maximising the oxygen reserves and delaying the onset of desaturation for several minutes in the event of a failed or difficult primary airway intervention [38]. Strategies for pre-oxygenation have improved over the last decades, targeting both the pre-induction phase, and the apnoea time after the induction of anaesthesia [39]. Pre-oxygenation was not included in the original template; however, the experts agreed that as pre-oxygenation might have a crucial effect on avoiding hypoxia during the apnoeic phase of TI and should be recorded [38].

Although RSI is standard practice for emergency anaesthesia in patients with a risk of pulmonary aspiration, the definition of RSI may not be uniform across international EMS services [32, 40]. RSI implies a transition from full consciousness with intact airway reflexes to complete unconsciousness. Ensuring optimal TI conditions with a high first pass success rate, backed up by rehearsed airway plans should the primary TI attempts fail, is important [20, 34]. Although the use of NMBA may increase TI success rates, a setting where the patient is rendered apnoeic may be challenging if primary airway management fails [36].

The most critical part of PHAAM may be the airway intervention itself, especially when performed during suboptimal conditions in the field [41]. Limiting the number of attempts is recommended, before declaring failed TI and proceeding with an alternative airway device [20]. Thus, specifying the number of attempts and type of device used in each attempt in sequential order may be important when documenting airway complications as an integral part of a patient safety culture. Rescue manoeuvres, such as backwards-upwards-rightwards-pressure or external laryngeal manipulation are manoeuvres commonly used to optimise TI conditions [34].This was not included in the original template, but the experts found that describing these manoeuvres in the revised dataset was useful.

In recent years, video laryngoscopy (VL) has been increasingly used in airway management [42, 43]. Although VL may improve the glottic view and be beneficial in the context of a difficult airway, little evidence exists today showing that VL reduces the number of TI attempts or airway complication rates, compared to direct laryngoscopy (DL) [44, 45]. As a technique involving an airway device, VL was not included in the original template. The benefit of VL in PHAAM still needs to be demonstrated, therefore the main types of VL and DL were included in the revised dataset.

The possibility of isolating different generic drugs used for PHAAM across patient categories might provide new knowledge, and the experts agreed to include the most common generic drugs used in PHAAM today.

The experts agreed that survival to hospital (short-term survival) should be recorded. Additionally, “dead on arrival” implies that no ALS procedures have been provided and should not be included. Rather, “dead on-scene after ALS interventions” or “alive on hospital arrival” should be documented. This categorisation includes patients being transported to the hospital with on-going mechanical chest compressions or extracorporeal cardiopulmonary resuscitation (ECPR) [46].

System variables

SOPs, including algorithms for unexpected difficult airway management, are emerging as an indispensable part of patient safety and quality systems [32]. The experts agreed that recording whether airway management SOPs are available in the individual EMS is important, also recognising the importance of developing robust clinical governance systems for pre-hospital critical care [47]. The experts agreed that the types of recurring airway management training provided by the EMS systems are important to record.

Value of standardised data

To be able to compare interventions or level of care across systems, standardized research data using common terminology, data definitions or quality indicators are required [48]. Developing common variables and definitions is an on-going process and it is important to identify the correct variables to use in airway research projects and for benchmarking of airway management across EMS [14]. The results from consensus processes such as ours are not the endpoint, as dissemination and implementation of the results into clinical service are the final aims [49]. A few EMS have successfully implemented the original template into clinical service; however, endorsement by internationally recognised airway societies, research groups, or key EMS stakeholders, along with interoperable health information systems, may be vital to secure a broad implantation of the airway template in international EMS [8, 50, 51].

The feasibility of collecting airway and trauma data using standardised templates have been shown, and it is important that data in comparative research projects are collected in a uniform manner [22, 48, 52]. To date, twenty-two articles have described data collection methods adhering to, or adapted to, the original Utstein-style airway template [3, 5, 8, 21,22,23, 50, 52,53,54,55,56,57,58,59,60,61,62,63,64,65,66]. A further twenty-three articles have referred to the original publication [6, 8, 13, 16, 35, 36, 41, 67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82]. However, as technology evolves, the availability of new possibilities of data capture from devices like video or body cameras, or streaming of monitor data directly to hospital data systems, may influence this kind of research [83, 84]. Therefore, how study data are obtained may be important to document to increase accuracy of data.


The scientific value of consensus methods, such as mNGT or the Delphi surveys, have been questioned, and no method is considered a “gold standard” [85]. Nonetheless, consensus methods are useful tools to assess agreement on questions for which hard evidence is difficult to obtain. We believe that recruiting a broad panel of experts according to predefined criteria, from fourteen countries across Europe, Australia and United States of America, may have reduced a possible selection bias and yielded a representative list of variables with scientific value. Keeping the preliminary email rounds and proposals anonymous from round one to three was important to avoid the influence of “loud-speaking” experts and to reduce the effect of a strong reputation or opinion on other more “silent-speaking” experts [9]. Each QA round was handled confidentially so that the experts were not aware of the answers or comments from the other experts.


Using a mNGT with international experts, we have updated the dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.’



Advanced life support




Direct laryngoscopy


Extracorporeal cardiopulmonary resuscitation


Emergency front of neck access


Emergency medical services


End-tidal carbon dioxide


Glasgow coma score


Helicopter emergency medical services


Modified nominal group technique


Neuromuscular blocking agents


Pre-hospital advanced airway management


Questionnaires and answers


Respiratory rate


Rapid sequence intubation


Supraglottic airway device


Standard operating procedure

SPO2 :

Peripheral oxygen saturation


Traumatic brain injury


Tracheal intubation


Video laryngoscopy


  1. 1.

    Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European resuscitation council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation. 2005;67(Suppl 1):S39–86.

  2. 2.

    Eich C, Roessler M, Nemeth M, Russo SG, Heuer JF, Timmermann A. Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians. Resuscitation. 2009;80:1371–7.

  3. 3.

    Lockey DJ, Crewdson K, Davies G, Jenkins B, Klein J, Laird C, et al. AAGBI: safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2017;72:379–90.

  4. 4.

    Fevang E, Perkins Z, Lockey D, Jeppesen E, Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care. 2017;21:192.

  5. 5.

    Lossius HM, Sollid SJ, Rehn M, Lockey DJ. Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables. Crit Care. 2011;15:R26.

  6. 6.

    Davis DP. The need for standardized data reporting for prehospital airway management. Crit Care. 2011;15:133.

  7. 7.

    Coats TJ. A revised Utstein template for trauma. Emerg Med J. 2010;27:339.

  8. 8.

    Lossius HM, Kruger AJ, Ringdal KG, Sollid SJ, Lockey DJ. Developing templates for uniform data documentation and reporting in critical care using a modified nominal group technique. Scand J Trauma Resusc Emerg Med. 2013;21:80.

  9. 9.

    Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(i-iv):1–88.

  10. 10.

    Castren M, Karlsten R, Lippert F, Christensen EF, Bovim E, Kvam AM, et al. Recommended guidelines for reporting on emergency medical dispatch when conducting research in emergency medicine: the Utstein style. Resuscitation. 2008;79:193–7.

  11. 11.

    Cummins RO, Chamberlain D, Hazinski MF, Nadkarni V, Kloeck W, Kramer E, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital ‘Utstein style’. American Heart Association Circulation. 1997;95:2213–39.

  12. 12.

    Idris AH, Becker LB, Ornato JP, Hedges JR, Bircher NG, Chandra NC, et al. Utstein-style guidelines for uniform reporting of laboratory CPR research. A statement for healthcare professionals from a task force of the American Heart Association, the American College of Emergency Physicians, the American College of Cardiology, the European resuscitation council, the Heart and Stroke Foundation of Canada, the Institute of Critical Care Medicine, the Safar Center for Resuscitation Research, and the Society for Academic Emergency Medicine. Writing group. Circulation. 1996;94:2324–36.

  13. 13.

    Kruger AJ, Lockey D, Kurola J, Di Bartolomeo S, Castren M, Mikkelsen S, et al. A consensus-based template for documenting and reporting in physician-staffed pre-hospital services. Scand J Trauma Resusc Emerg Med. 2011;19:71.

  14. 14.

    Ringdal KG, Coats TJ, Lefering R, Di Bartolomeo S, Steen PA, Roise O, et al. The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG. Scand J Trauma Resusc Emerg Med. 2008;16:7.

  15. 15.

    Dick WF, Baskett PJ. Recommendations for uniform reporting of data following major trauma--the Utstein style. A report of a working party of the international trauma Anaesthesia and critical care society (ITACCS). Resuscitation. 1999;42:81–100.

  16. 16.

    Fattah S, Rehn M, Lockey D, Thompson J, Lossius HM, Wisborg T, et al. A consensus based template for reporting of pre-hospital major incident medical management. Scand J Trauma Resusc Emerg Med. 2014;22:5.

  17. 17.

    Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, et al. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”. Circulation. 2003;108:2565–74.

  18. 18.

    Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a task force of the American Heart Association, the European resuscitation council, the Heart and Stroke Foundation of Canada, and the Australian resuscitation council. Circulation. 1991;84:960–75.

  19. 19.

    Zaritsky A, Nadkarni V, Hazinski MF, Foltin G, Quan L, Wright J, et al. Recommended guidelines for uniform reporting of pediatric advanced life support: the pediatric Utstein style. A statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European resuscitation council. Resuscitation. 1995;30:95–115.

  20. 20.

    Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–48.

  21. 21.

    Sollid SJ, Lockey D, Lossius HM. Pre-hospital advanced airway management expert g. A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. Scand J Trauma Resusc Emerg Med. 2009;17:58.

  22. 22.

    Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, et al. Airway management by physician-staffed helicopter emergency medical services - a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med. 2015;23:57.

  23. 23.

    Sunde GA, Sandberg M, Lyon R, Fredriksen K, Burns B, Hufthammer KO, et al. Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-Centre study. BMC Emerg Med. 2017;17:22.

  24. 24.

    Castrén M, Bohm K, Kvam AM, Bovim E, Christensen EF, Steen-Hansen JE, et al. Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching - taking the recommendations on reporting OHCA the Utstein style a step further. Resuscitation. 2011;82:1496-500.

  25. 25.

    Cook TM, Woodall N, Frerk C, Fourth National Audit P. major complications of airway management in the UK: results of the fourth National Audit Project of the Royal College of Anaesthetists and the difficult airway society. Part 1: anaesthesia. Br J Anaesth. 2011;106:617–31.

  26. 26.

    Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17:R76.

  27. 27.

    Bossers SM, Schwarte LA, Loer SA, Twisk JW, Boer C, Schober P. Experience in prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: a systematic review and meta-analysis. PLoS One. 2015;10:e0141034.

  28. 28.

    Helm M, Hossfeld B, Schafer S, Hoitz J, Lampl L. Factors influencing emergency intubation in the pre-hospital setting--a multicentre study in the German helicopter emergency medical service. Br J Anaesth. 2006;96:67–71.

  29. 29.

    Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S, Margenet A, et al. Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad Emerg Med. 2006;13:828–34.

  30. 30.

    Fleming S, Thompson M, Stevens R, Heneghan C, Pluddemann A, Maconochie I, et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet. 2011;377:1011–8.

  31. 31.

    Heradstveit BE, Sunde K, Sunde GA, Wentzel-Larsen T, Heltne JK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest--a clinical retrospective study in 575 patients. Resuscitation. 2012;83:813–8.

  32. 32.

    Sherren PB, Tricklebank S, Glover G. Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill. Scand J Trauma Resusc Emerg Med. 2014;22:41.

  33. 33.

    Janz DR, Semler MW, Joffe AM, Casey JD, Lentz RJ, deBoisblanc BP, et al. A multicenter randomized trial of a checklist for endotracheal intubation of critically ill adults. Chest. 2018;153:816–24.

  34. 34.

    Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004;59:675–94.

  35. 35.

    Crewdson K, Lockey DJ, Roislien J, Lossius HM, Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017;21:31.

  36. 36.

    Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia: the same but different. Br J Anaesth. 2014;113:211–9.

  37. 37.

    Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86:635–9.

  38. 38.

    Bouroche G, Bourgain JL. Preoxygenation and general anesthesia: a review. Minerva Anestesiol. 2015;81:910–20.

  39. 39.

    McNarry AF, Patel A. The evolution of airway management - new concepts and conflicts with traditional practice. Br J Anaesth. 2017;119:i154–i66.

  40. 40.

    Koerber JP, Roberts GE, Whitaker R, Thorpe CM. Variation in rapid sequence induction techniques: current practice in Wales. Anaesthesia. 2009;64:54–9.

  41. 41.

    Burns B, Habig K, Eason H, Ware S. Difficult intubation factors in prehospital rapid sequence intubation by an Australian helicopter emergency medical service. Air Med J. 2016;35:28–32.

  42. 42.

    Cavus E, Callies A, Doerges V, Heller G, Merz S, Rosch P, et al. The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study. Emerg Med J. 2011;28:650–3.

  43. 43.

    Mosier J, Chiu S, Patanwala AE, Sakles JC. A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department. Ann Emerg Med. 2013;61:414–20 e1.

  44. 44.

    Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane systematic review. Br J Anaesth. 2017;119:369–83.

  45. 45.

    Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21:288.

  46. 46.

    Tisherman SA, Menaker J, Kon Z. Are we ready to take ECPR on the road? Maybe. Resuscitation. 2017;117:A1–2.

  47. 47.

    Nutbeam T. Clinical governance and prehospital care in the UK. Emerg Med J. 2011;28:91–2.

  48. 48.

    Ringdal KG, Lossius HM, Jones JM, Lauritsen JM, Coats TJ, Palmer CS, et al. Collecting core data in severely injured patients using a consensus trauma template: an international multicentre study. Crit Care. 2011;15:R237.

  49. 49.

    Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:376–80.

  50. 50.

    Angerman S, Kirves H, Nurmi J. A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation. Anaesthesia. 2018;73:348–55.

  51. 51.

    Anani N, Mazya MV, Chen R, Prazeres Moreira T, Bill O, Ahmed N, et al. Applying openEHR’s guideline definition language to the SITS international stroke treatment registry: a European retrospective observational study. BMC medical informatics and decision making. 2017;17:7.

  52. 52.

    Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Predicting the lack of ROSC during pre-hospital CPR: should an end-tidal CO2 of 1.3 kPa be used as a cut-off value? Resuscitation. 2014;85:332–5.

  53. 53.

    Chesters A, Keefe N, Mauger J, Lockey D. Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J. 2014;31:65–8.

  54. 54.

    Gellerfors M, Fevang E, Backman A, Kruger A, Mikkelsen S, Nurmi J, et al. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth. 2018;120:1103–9.

  55. 55.

    Lankimaki S, Alahuhta S, Silfvast T, Kurola J. Feasibility of LMA supreme for airway management in unconscious patients by ALS paramedics. Scand J Trauma Resusc Emerg Med. 2015;23:24.

  56. 56.

    Lockey DJ, Avery P, Harris T, Davies GE, Lossius HM. A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the ‘quick look’ airway assessment. BMC Anesthesiol. 2013;13:21.

  57. 57.

    McQueen C, Crombie N, Hulme J, Cormack S, Hussain N, Ludwig F, et al. Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice. Emerg Med J. 2015;32:65–9.

  58. 58.

    Nevin DG, Green SJ, Weaver AE, Lockey DJ. An observational study of paediatric pre-hospital intubation and anaesthesia in 1933 children attended by a physician-led, pre-hospital trauma service. Resuscitation. 2014;85:189–95.

  59. 59.

    Rhode MG, Vandborg MP, Bladt V, Rognas L. Video laryngoscopy in pre-hospital critical care - a quality improvement study. Scand J Trauma Resusc Emerg Med. 2016;24:84.

  60. 60.

    Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013;21:58.

  61. 61.

    Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service. Scand J Trauma Resusc Emerg Med. 2013;21:75.

  62. 62.

    Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Standard operating procedure changed pre-hospital critical care anaesthesiologists’ behaviour: a quality control study. Scand J Trauma Resusc Emerg Med. 2013;21:84.

  63. 63.

    Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study. Eur J Emerg Med. 2014;21:418–23.

  64. 64.

    Raatiniemi L, Lankimaki S, Martikainen M. Pre-hospital airway management by non-physicians in northern Finland -- a cross-sectional survey. Acta Anaesthesiol Scand. 2013;57:654–9.

  65. 65.

    Tarpgaard M, Hansen TM, Rognas L. Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study. Scand J Trauma Resusc Emerg Med. 2015;23:61.

  66. 66.

    Weatherall A, Garner A, Lovell N, Redmond S, Lee A, Skowno J, et al. Study protocol for the PHANTOM study: prehospital assessment of noninvasive tissue oximetry monitoring. Scand J Trauma Resusc Emerg Med. 2014;22:57.

  67. 67.

    Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann HC, Arntz HR. Difficult prehospital endotracheal intubation - predisposing factors in a physician based EMS. Resuscitation. 2011;82:1519–24.

  68. 68.

    Burns BJ, Watterson JB, Ware S, Regan L, Reid C. Analysis of out-of-hospital pediatric intubation by an Australian helicopter emergency medical service. Ann Emerg Med. 2017;70:773–82 e4.

  69. 69.

    Crewdson K, Lockey D. Advanced airway management for pre-hospital trauma patients. Trauma. 2015;18:111–8.

  70. 70.

    de la Encina MEC, Quiles AS, Vicente-Mazariegos ID, Aracil NG, Alcaide LJ, Martinez MR. Efficacy and safety of endotracheal intubation performed in moving vs motionless environments. Emergencias. 2017;29:5–10.

  71. 71.

    Debacker M, Hubloue I, Dhondt E, Rockenschaub G, Ruter A, Codreanu T, et al. Utstein-style template for uniform data reporting of acute medical response in disasters. PLoS Curr. 2012;4:e4f6cf3e8df15a.

  72. 72.

    Fevang E, Lockey D, Thompson J, Lossius HM, Torpo Research C. The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration. Scand J Trauma Resusc Emerg Med. 2011;19:57.

  73. 73.

    Fouche PF, Middleton PM, Zverinova KM. Training and experience are more important than the type of practitioner for intubation success. Crit Care. 2013;17:412.

  74. 74.

    Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician out-of-hospital rapid sequence intubation success and adverse events: a systematic review and meta-analysis. Ann Emerg Med. 2017;70:449–59. e20

  75. 75.

    Fullerton JN, Roberts KJ, Wyse M. Should non-anaesthetists perform pre-hospital rapid sequence induction? An observational study. Emerg Med J. 2011;28:428–31.

  76. 76.

    Lockey D, Lossius HM. Pre-hospital airway management: the data grows rapidly but controversy remains. Resuscitation. 2014;85:849–50.

  77. 77.

    Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42:1372–8.

  78. 78.

    Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognas L, et al. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand. 2016;60:852–64.

  79. 79.

    Rognas LK, Hansen TM. EMS-physicians’ self reported airway management training and expertise; a descriptive study from the central region of Denmark. Scand J Trauma Resusc Emerg Med. 2011;19:10.

  80. 80.

    Sollid SJ, Lossius HM, Nakstad AR, Aven T, Soreide E. Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach. Scand J Trauma Resusc Emerg Med. 2010;18:22.

  81. 81.

    Sollid SJ, Lossius HM, Soreide E. Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med. 2010;18:30.

  82. 82.

    Wigman LD, van Lieshout EM, de Ronde G, Patka P, Schipper IB. Trauma-related dispatch criteria for helicopter emergency medical Services in Europe. Injury. 2011;42:525–33.

  83. 83.

    Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg. 2013;75:212–9.

  84. 84.

    Voigt R, Camp NP, Prabhakaran V, Hamilton WL, Hetey RC, Griffiths CM, et al. Language from police body camera footage shows racial disparities in officer respect. Proc Natl Acad Sci U S A. 2017;114:6521–6.

  85. 85.

    Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics and guidelines for use. Am J Public Health. 1984;74:979–83.

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Our sincerest thanks go to the international airway expert group who made this study possible: Ilkka Virkkunen, Wolfgang Voelckel, Peter Paal, Lorenz Theiler, Massimiliano Sorbello, Richard Lyon, Kate Crewdson, Brian Burns, Leif Rognås, Björn Hossfeld, Alasdair Corfield, Daniel Davis, Tomasz Gaszyński, and Pavel Michalek. We extend a special gratitude to international research coordinator Kirsti Strømmen Holm at the Norwegian Air Ambulance Foundation for her invaluable work in coordinating all QAs in the email rounds with the experts and arranging the consensus group meeting. Lastly, we extend our appreciation to the Lærdal Foundation for their support towards the consensus meeting of the international airway experts.


Financial support and sponsorship: The Norwegian Air Ambulance Foundation funds the part time PhD-grant (50%) for GAS, the full time PhD-grant for AK, and is the main funding source of the academic positions for two of the supervisors (JKH and SJMS). The SICPA Foundation granted AK for a research fellowship in Norway. The participating experts received no financial support for their participation in this study. A grant of 75 000 NOK (Grant 3341) was awarded from the Lærdal Foundation towards two projects: one revising the airway template and one developing quality indicators for pre-hospital airway management. The grant contributed to the accomplishment of the consensus meeting of experts. The Norwegian Air Ambulance Foundation and the Lærdal Foundation, however, had no authority in any part of the study design, project management, data collection, data analysis or interpretation, writing of the manuscript or publication.

Availability of data and materials

The datasets generated during this study are included in this published article.

Author information

GAS conceived the study, designed the study protocol, was responsible for the ethical applications in Norway, developed the questionnaires for the consensus rounds, contributed to the data collection and analysis, and wrote the first and final drafts of the manuscript. AK conceived the study, designed the study protocol, developed the questionnaires for the consensus rounds, contributed to the data collection and analysis, and helped draft the manuscript. JKH aided in the design of the study protocol, contributed to the data collection and analysis, and helped draft the manuscript. MS contributed to the data collection and analysis and helped draft the manuscript. MG contributed to the data collection and analysis and helped draft the manuscript. AKR aided in the design of the study protocol, contributed to the data collection and analysis, and helped draft the manuscript. DL aided in the design of study and the drafting of the manuscript. SJMS aided in the design of the study protocol, contributed to the data collection and analysis, moderated the consensus meeting, and helped draft the manuscript. All authors read and approved the final manuscript.

Correspondence to G. A. Sunde.

Ethics declarations

Ethics approval and consent to participate

Not applicable. The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review as it did not include human research data (Reference: REK-Vest/2017/260).

Competing interests

The authors declare that they have no competing interests.

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Additional files

Additional file 1:

Questionnaire first email round. (XLSX 24 kb)

Additional file 2:

Questionnaire second email round. (XLSX 21 kb)

Additional file 3:

Questionnaire third email round. (XLSX 20 kb)

Additional file 4:

Expert group composition. (DOCX 140 kb)

Additional file 5:

Questionnaire consensus meeting. (XLSX 17 kb)

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  • Airway management
  • Air ambulances
  • Emergency medical services
  • Intubation
  • Data accuracy