Confined space airway management (CSAM) refers to the delivery of airway interventions in environments where physical space is severely restricted, limiting patient access, rescuer mobility, and equipment use. These settings may be controlled—such as helicopter cabins or ambulances with known layouts and standard operating procedures—or uncontrolled, including vehicle entrapments, structural collapses, or industrial accidents, where unpredictability and operational hazards dominate.
In a recent narrative review published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2025), Rudolph et al. synthesize current knowledge and expert opinion on CSAM. This collaborative effort by clinicians and researchers from Denmark, the United States, Sweden, Switzerland, and Germany offers valuable insights into a high-acuity but under-researched domain of prehospital care. Also two members of the Protected Airway Collaborative contributed to this article.
Tracheal Intubation
Tracheal intubation (TI) becomes substantially more challenging in confined environments. Limited access to the patient’s head, suboptimal ergonomics, and space constraints can reduce first-pass success and increase complication rates. The review underscores the critical role of rescuer positioning in mitigating these challenges. Positions such as kneeling, straddling, lateral, and prone have been proposed, each with situational advantages and ergonomic trade-offs.
However, even with adjuncts like bougies or hyperangulated video laryngoscopes, TI in confined spaces should be deferred until after extrication whenever possible. Ideally, clinicians should strive to recreate a hospital-like setting: the patient positioned supine on a stretcher, with 360° access, standardized equipment, and a well-coordinated team. These conditions remain the gold standard for safe and effective tracheal intubation.
Illustrations of rescuer positioning for tracheal intubation. A Sitting position, B kneeling position, Cstraddling position, D prone position, E left lateral position, F right lateral position
Supraglottic Airways
Given the limitations and risks of TI in confined spaces, supraglottic airway (SGA) devices are recommended as the primary approach. Their ease of insertion, high success rates, and minimal reliance on head positioning make them particularly suited for constrained environments. Numerous manikin studies cited in the review highlight effective performance with SGAs such as the iGel®, LMA Supreme®, and King LT®.
Notably, SGAs also perform well across a range of provider experience levels, offering a reliable and efficient bridge to definitive airway control—particularly valuable when time, space, and resources are limited.
emergency Front-of-Neck Access
Among all techniques examined, emergency front-of-neck access (eFONA)—particularly surgical cricothyrotomy—was the only intervention to consistently show high success rates in all identified manikin studies. Given this reliability, open surgical cricothyrotomy may even be considered a first-line option, particularly in cases where SGA success is unlikely, such as in severe facial trauma or burns.
Summary
The fundamental principles of emergency airway management apply equally in confined spaces: standardized preparation of the patient, environment, and team is essential. However, CSAM requires an added layer of logistical adaptability and situational awareness. Oxygenation—not procedural completion—must remain the top priority. In these high-stakes scenarios, the safest airway is often not the most definitive one, but the one that is most rapidly and reliably achieved.
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