Cardiopulmonary Resuscitation and Airway Management

Key Points

• Cardiac arrest is a leading cause of mortality.

• Current AHA Guidelines recommend chest compressions before initial airway management.

• Ventilation and oxygenation during CPR can be performed via bag mask ventilation or an advanced airway device (either an endotracheal tube or a supraglottic airway).

• Interruptions in chest compressions should be minimized during airway management.

• Hyperventilation should be avoided during CPR.

• Ventilation plays a larger role in pediatric and neonatal resuscitation and high levels of supplemental oxygen should be avoided in neonates.

Chapter Outline

• Introduction

• Basic Life Support and Cardiopulmonary Resuscitation Guidelines

  • Changes to AHA Guidelines 2010–2015

  • AHA Updated Guidelines 2015-2020

• Initial Airway Management During Cardiopulmonary Resuscitation

  • Rescue Breathing

  • Airway Adjuncts

• Advanced Airway Management During Cardiopulmonary Resuscitation

  • Confirmation of Endotracheal Tube Placement During Cardiopulmonary Resuscitation

  • Supraglottic Airway Devices

  • Role of Advanced Airway Devices

  • Use of Cricoid Pressure During Cardiopulmonary Resuscitation

• Alternative Methods of Oxygen Delivery During Cardiopulmonary Resuscitation

  • Oxylator

  • ResQPODPassive Oxygen Insufflation

• Airway Management Postintubation and after Return of Spontaneous Circulation

• Challenges of Airway Management During Cardiopulmonary Resuscitation

  • Access to the Airway

• Infection Risk During CPR and Airway ManagementCervical Spine InjuryEquipment Challenges

• Controversies

  • Role of Hyperventilation

  • When to Secure the Airway

  • Supraglottic Airway Device Versus Endotracheal Intubation as an Advanced Airway Technique

• Pediatric Basic and Advanced Life Support and Resuscitation

• Neonatal Basic and Advanced Life Support and Resuscitation Clinical Pearls

• Conclusion

Introduction

Cardiac arrest is one of the leading causes of mortality in the United States. Most cardiac arrests occur outside the hospital, usually in the home, and 50% of arrests are unwitnessed. In-hospital cardiac arrests (IHCA) have a more favorable outcome than out-of-hospital cardiac arrests (OHCA). The average survival to discharge for adult OHCA patients who receive cardiopulmonary resuscitation (CPR) ranges from 3.4% to 22%, with a 10.4% survival rate after initial hospitalization and 8.2% survival rate with good functional outcome. Among adults admitted to hospitals, 1.2% suffer from IHCA, and of those, 25.8% were discharged from the hospital, and 82% of those survivors had good functional status. Early CPR and defibrillation are recognized as the most important treatment steps for cardiac arrest, but adequate oxygenation and ventilation are also important for providing oxygen to vital organ systems. Although earlier American Heart Association (AHA) CPR guidelines focused on the airway and ventilation as first steps in resuscitation, more recent versions have placed a stronger emphasis on rapid return of circulation.

The most common etiology of cardiac arrest in adult patients outside the hospital setting is cardiac in nature, most often ventricular fibrillation. In the hospital, however, cardiac arrest may be because of cardiac or pulmonary causes. Most first responders outside the hospital are not trained in advanced airway management; therefore, the AHA CPR guidelines related to airway management are different for lay rescuers than for in-hospital providers.

Basic Life Support and Cardiopulmonary Resuscitation Guidelines

The initial 2005 AHA guidelines for basic life support (BLS) and CPR recommended the sequence of airway, breathing, and circulation (A-B-C). Thus, the first steps in the 2005 BLS guidelines were opening the airway, checking for breathing, and providing 2 rescue breaths if adequate breathing was not detected. The third step was to initiate chest compressions ( Fig. 32.1 ). To check for breathing, lay rescuers and healthcare providers were advised to “look, listen, and feel.” Healthcare providers were then advised to check for a pulse after delivering the initial rescue breaths to a nonresponsive, nonbreathing individual.

The 2005 AHA CPR guidelines recommended 2 rescue breaths, each given over 1 second, with sufficient tidal volume to produce visual chest rise. If an advanced airway was in place, the guidelines recommended 8 to 10 breaths per minute without synchronizing breaths between chest compressions.

AHA Updated Guidelines 2015–2020

Since 2015, the AHA has released yearly focused updates based on updated evidence, as well as updated guidelines in 2020 that incorporated updated recommendations from the previous focused updates. ^, The 2020 guidelines stress that if a patient demonstrates agonal breathing or gasping respiration, lay rescuers should assume the patient is in cardiac arrest and begin CPR. The steps and recommendations provided in Tables 32.1 and 32.2 remain unchanged in the updated 2020 guidelines.

The 2019 focused update provided updated recommendations for the use of advanced airway devices and stressed the need for training and use of capnography, and these recommendations are incorporated into the 2020 updated guidelines as well ^, ( Box 32.3 ). Both the 2019 and 2020 guidelines also support previous versions to avoid interruptions in chest compressions for airway management, suggesting that advanced airway management can be delayed until after two rounds of chest compressions or even until after ROSC if bag-mask ventilation is adequate. The 2020 updated adult BLS algorithm for healthcare providers is shown in Fig. 32.2 . The only change in this algorithm from the 2010 and 2015 versions is the simplification to provide rescue breathing every 6 seconds or 10 breaths per minute. The 2020 updated AHA guidelines also recommend that either a supraglottic airway (SGA) or an endotracheal tube (ETT) can be considered as an advanced airway technique and that an SGA may be preferred over an ETT in settings with minimal training opportunities or low intubation success rates ( Fig. 32.3 ).

Box 32.3

2020 Adult Basic and Advanced Cardiac Life Support Guidelines: Additional Changes in Airway Management Since 2015

CPR , cardiopulmonary resuscitation, ETT , endotracheal tube; SGA , supraglottic airway.

• 1.

  If a patient demonstrates agonal breathing or gasping respiration, lay rescuers should assume the patient is in cardiac arrest and begin CPR.

• 2.

  Rescue breathing was simplified to 10 breaths/minute.

• 3.

  Either bag-mask ventilation or an advanced airway may be considered during CPR in any setting.

• 4.

  Either a supraglottic airway (SGA) or an endotracheal tube (ETT) can be considered as an advanced airway technique,

• 5.

  In settings with minimal training opportunities or low intubation success rates, an SGA may be preferred.

• 6.

  Waveform capnography should be used to confirm and monitor ETT placement, including during transport.

Initial Airway Management During Cardiopulmonary Resuscitation

Advanced Airway Management During Cardiopulmonary Resuscitation

The primary goal of airway management during CPR should be to provide adequate oxygenation and ventilation. If bag-mask ventilation is adequate and an advanced airway strategy will interrupt chest compressions, current AHA guidelines suggest that insertion of an advanced airway can be deferred until either ROSC occurs or the patient fails to respond to chest compressions and defibrillation. If bag-mask ventilation is not adequate, however, an advanced airway should be placed.

Trained healthcare providers should perform tracheal intubation during CPR while minimizing interruptions in chest compressions. Tracheal intubation performed by direct laryngoscopy may be more difficult if performed during chest compressions. Prolonged attempts at tracheal intubation should be avoided, especially if chest compressions are halted during attempts. Placement of an endotracheal tube (ETT) or another advanced airway device has not been associated with any improvement in ROSC. Tracheal intubation attempts by inexperienced providers may result in complications, such as failed intubation or esophageal intubation.

After ETT placement, ventilations are delivered without interruption of chest compressions at a rate of 1 breath every 6 seconds. Certain resuscitation medications can be delivered through the ETT ( Box 32.4 ). Secretions can be removed from the airway through the ETT, and the ETT cuff may provide a barrier against aspiration. Per the 2020 updated AHA advanced cardiovascular life support (ACLS) guidelines, in order to use advanced airway devices effectively, healthcare providers should maintain their knowledge and skills through frequent practice. In addition to mastering bag-mask ventilation, providers should master an advanced airway strategy and a second (backup) stra­tegy for use.

More recent studies comparing the use of an SGA versus an ETT demonstrate no difference in survival or neurological outcome between the two techniques. Therefore, the most recent guidelines recommend that providers can use either advanced airway technique during CPR in any setting (OHCA or IHCA). Since the success of advanced airway placement is highly dependent on provider skill set, either bag-mask ventilation or an advanced airway is considered acceptable during CPR. If an advanced airway is used, an SGA can be used in settings with low intubation success rate or minimal training for ETT placement, whereas in settings where ETT placement success is high with optimal training, either an SGA or ETT can be used. See Fig. 32.3 for the current recommendations related to advanced airway management in patients with cardiac arrest.