Advanced Airways in Cardiac Arrest

Introduction to Advanced Airways

The American Heart Association recommends the use of advanced airways, including endotracheal tubes and supraglottic airway devices, to maintain an open airway and facilitate ventilation during cardiac arrest and other emergency situations 1, 2

Endotracheal intubation provides the most secure airway with the best protection against aspiration, but requires direct visualization of the glottis, which often necessitates interruption of chest compressions during cardiac arrest 1, 2, 3
Confirmation of correct placement requires waveform capnography (Class I, LOE A) in addition to clinical assessment 4
Colorimetric CO2 detectors or esophageal detector devices can be used as initial confirmation methods when waveform capnography is unavailable (Class IIa, LOE B) 4

Supraglottic airways, such as the esophageal-tracheal tube (Combitube), can function whether placed in the esophagus or trachea, providing isolation of the airway and reducing the risk of aspiration 1, 2
The Combitube provides successful ventilation during CPR in 62% to 100% of patients and is an acceptable alternative to both bag-mask ventilation (Class IIa, LOE C) and endotracheal intubation (Class IIa, LOE A) 1

Supraglottic airways do not require visualization of the glottis, making initial training and skill maintenance easier, and can be inserted without interrupting chest compressions during CPR 1, 2
During CPR performed by trained providers, supraglottic airways are reasonable alternatives to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A) 1

Once an advanced airway is in place, providers should no longer deliver cycles of CPR with pauses for ventilation, and should give continuous chest compressions at a rate of at least 100 per minute 1
The ventilating provider should deliver 1 breath every 6-8 seconds (8-10 breaths/minute) 1
Providers should avoid excessive ventilation rates as this can compromise venous return and cardiac output 1

Selection of an advanced airway should be based on provider training and experience 5
For healthcare professionals trained in their use, supraglottic airways are reasonable alternatives to endotracheal intubation during cardiac arrest 1, 6

Endotracheal intubation provides the most secure airway with best protection against aspiration, and enables delivery of a selected tidal volume and provides an alternative route for drug administration, according to the American Heart Association 7
Endotracheal intubation requires more advanced skills and training to perform correctly, and is associated with complications when performed by inexperienced providers, including unrecognized esophageal intubation 7, 8
The King Laryngeal Tube can be inserted without direct visualization of the vocal cords, requires less training to use effectively, and provides effective ventilation during CPR in most cases 7, 8
The King Laryngeal Tube does not provide absolute protection against aspiration 7

The American Heart Association states that for healthcare professionals trained in their use, supraglottic airways are a reasonable alternative to bag-mask ventilation and endotracheal intubation for airway management during cardiac arrest (Class IIa, LOE A) 8
The King Laryngeal Tube may be considered as an alternative to bag-mask ventilation or endotracheal intubation for airway management in cardiac arrest (Class IIb, LOE C) 8
Provider experience and training should guide the choice of advanced airway 7

Successful ventilation rates with the King Laryngeal Tube range from 85-97% in cardiac arrest settings 8
Frequent training and experience are essential for maintaining skills with any advanced airway technique 8

The American Heart Association recommends using supraglottic airway (SGA) devices in settings with low endotracheal intubation (ETI) success rates (<70%), as they demonstrate superior outcomes when ETI success rates are suboptimal 9, 10
In settings with high ETI success rates (>90%), either device is acceptable, as outcomes are equivalent 9, 11

For out-of-hospital cardiac arrest (OHCA) in low-skill environments (ETI success <70%), prefer SGA devices, as they improved survival to discharge (RR 1.34, 95% CI 1.07-1.68) and neurologically favorable survival (RR 1.42, 95% CI 1.07-1.89) compared to ETI in settings with 52% intubation success 9, 12
In high-skill environments (ETI success >90%), either ETI or SGA is acceptable, with no difference in survival (RR 0.95) or neurological outcomes (RR 0.92) 9, 10

ETI requires frequent experience and retraining (Class 1 recommendation), with successful ETI associated with improved survival (adjusted OR 1.40) compared to SGA in optimal performance conditions 9, 10
The American Heart Association guidelines showed ETI success rates ranging from 52% to 98%, demonstrating massive variability based on provider experience 9, 13

All EMS systems performing prehospital intubation must provide ongoing quality improvement programs (Class 1 recommendation), track overall SGA and ETT placement success rates, and monitor complications systematically 9, 11
The American Heart Association recommends tracking overall SGA and ETT placement success rates, and monitoring complications systematically 9, 10

The American Heart Association is not mentioned in the cited fact, however, the British Journal of Anaesthesia suggests that SGAs do not require direct visualization of the glottis, making initial training and skill maintenance easier, and can be inserted without interrupting CPR during cardiac arrest 14

Manual in-line stabilization should be applied during intubation rather than relying solely on cervical collar immobilization when cervical spine injury is suspected, as recommended by Anaesthesia 15