Airway Management in Out-of-Hospital Cardiac Arrest
Direct Recommendation
- The International Consensus on CPR provides a weak recommendation for bag-mask ventilation OR advanced airway strategy during CPR (low to moderate certainty evidence) 1
- In settings with low intubation success rates, the American Heart Association suggests supraglottic airways (SGAs) over endotracheal intubation (ETT) for out-of-hospital cardiac arrest 1
- In settings with high intubation success rates, either SGA or ETT is acceptable 1
Evidence-Based Decision Framework
Primary Outcome Evidence
- The American Heart Association states that there is no evidence that advanced airway measures improve survival rates compared to bag-mask ventilation in out-of-hospital cardiac arrest 2
Practical Performance Advantages of SGAs
- SGAs can be inserted without interrupting chest compressions, unlike ETT which requires direct visualization 2, 3
- The American Heart Association recommends that SGAs are a reasonable alternative to both bag-mask ventilation and endotracheal intubation (Class IIa, LOE B and Class IIa, LOE A) 2
Algorithm for Clinical Decision-Making
- If providers lack frequent ETT experience or training, the American Heart Association recommends choosing SGA 1, 3
- SGAs require less training and skill maintenance than ETT 2, 3
Confirmation of Placement
- The American Heart Association strongly recommends waveform capnography for ETT confirmation 1
- The American Heart Association recommends using nonwaveform CO2 detector or esophageal detector device if waveform capnography is unavailable 1
Common Pitfalls to Avoid
- The American Heart Association warns against prolonged intubation attempts causing excessive interruption in compressions 4
- The American Heart Association warns against unrecognized esophageal intubation 3, 5