Airway management during CPR

Jerry Nolan
Royal United Hospital, Bath, UK

18 March 2016

Conflicts of interest

Editor-in-Chief
Resuscitation
Author ERC
Guidelines
Co-investigator for
AIRWAYS-2 trial

Airway management during CPR

Objectives of airway management during

CPR
Tracheal intubation pros and cons
Supraglottic airways
Existing evidence
Ongoing trials

Objectives of airway
management during CPR

Improve ROSC and long-term survival

Enable oxygenation and ventilation despite
potentially poor lung compliance
(continuous chest compressions)
Protect against aspiration
Minimise no flow time
Minimise complications

Tracheal intubation during CPR:

advantages

Enables uninterrupted chest

compressions
Enables most effective
ventilation?
Least likely airway to be
dislodged?
Minimises gastric inflation
Protects against aspiration

The intubation learning curve

Bernhard M. Acta Anaesthesiol Scand 2012;56:164-71

21 first-year anaesthesia residents, Heidelberg, Germany

13 studies; total of 1462 students;

attempting to intubate 19,108 patients
In elective setting: at least 50 intubations
with no more that two attempts to
achieve success rate of 90%.
Heterogeneous data likely many more
required in non-elective settings
Resuscitation 2016;99:6371

Intubation success: cardiac arrest

Study
Bradley, 1998

Intubator

Success (%)

57 EMT

49

Sayre, 1998

103 EMT

51

Rumball, 2004

250 EMT

70

Rabitsch, 2003
Stiell, 2004

83 Physician

94

3848 Paramedic

93.7

Deakin, 2010

368 Paramedic

83.8

Lyon, 2010

628 Paramedic

91.2

Stiell, 2011 (ROC)

7651 EMS

89.3

Nichol 2015 (ROC) 13623 EMS

84.3

Interruptions in CPR from

tracheal intubation (U.S.)

100 cardiac arrests with real-time data

collection including audio
1st tracheal intubationassociated CPR
interruption = 46.5 s (IQR 23.5 73 s;
range 7 to 221 s).
One third exceeded 1 minute.

Wang HE. Ann Emerg Med. 2009;54:645-652

Intubations by paramedics,
Hampshire, UK 2007

439 tracheal intubation attempts

documented by 269 paramedics.
368 (83.8%) documented successful.

Intubations

9 10 11

Paramedics 128 76 28 22

Deakin C. EMJ 2009;26:888-91

Unrecognised oesophageal
intubations: cardiac arrest
Study
Lyon RM, 2010
Sayre MR, 1998
Rumball C, 2004
Pellucio M, 1997
Jones JH, 2004
Katz SH, 2001

Number (%)
15/628 (2.4)
3/103 (2.9)
7/208 (3.0)
10/168 (6.0)
10/160 (6.3)
18/108 (16.7)

Soar J, Callaway CW et al. Resuscitation 2015;95:e71e120

Waveform capnography is recommended to

confirm & continuously monitor the position of a
tracheal tube during CPR in addition to clinical
assessment (strong recommendation, low quality
evidence).
We recommend that if waveform capnography is
not available, a non-waveform CO2 detector,
esophageal detector device, or ultrasound in
addition to clinical assessment is an alternative
(strong recommendation, low quality evidence).

2015 ERC Guidelines: Waveform capnography

must be used for confirming tracheal tube
placement and monitoring ventilation rate.

i-gel

LMA Supreme

Laryngeal Tube

73.2%

70.6%

76.7%

72.4%

Post adjustment difference in favour of SGA:

Pre-airway 2.2% (P=0.046)
Post-airway 3.4% (P=0.001)
Kurz MC. Resuscitation 2016;98:3540

JAMA 2013;309:257-66

All-Japan Utstein Registry 2005 - 2010

N=649,359
N

Tracheal tube
41,972 (6%)

SGA
239,550 (37%)

Bag-mask
367,837 (57%)

CPC 1-2 (1 month)

1.0%

1.1%

2.9%

Adjusted OR for
good outcome vs.
BVM (95% CI)

0.32 (0.29-0.36)

0.32 (0.30-0.33)

NA

Resuscitation 2015;93:206

Survival to hospital discharge CPC 1-2

Resuscitation 2015;93:206

Resuscitation 2012;83:1025-30
% change carotid flow compared with tracheal tube

9 pigs

17 patients
undergoing CT scans
with SGA in situ
Retrospective
No vital signs data
available
Human carotid
arteries more lateral
than in animals
White JMB. Acad Emerg Med 2015;22:6368

Soar J, Callaway CW et al. Resuscitation 2015;95:e71e120

We suggest using either an

advanced airway or a bag-mask
device for airway management during
CPR (weak recommendation, very-lowquality evidence) for cardiac arrest in
any setting.
We suggest using either an SGA or
tracheal tube as the initial advanced
airway during CPR (weak
recommendation, very-low-quality
evidence) for cardiac arrest in any
setting.

Soar J, Callaway CW et al. Resuscitation 2015;95:e71e120

Values and preferences

The type of airway used may depend on the skills

and training of the healthcare provider. Tracheal
intubation requires more training and practice.
Tracheal intubation may result in unrecognized
esophageal intubation and increased hands-off
time in comparison with insertion of an SGA.
Both an SGA and tracheal tube are frequently used
in the same patients as part of a stepwise
approach to airway management, but this has not
been formally assessed.

BJA 2016;116:2628

171 paramedics randomised and trained

615 cardiac arrests
Neurological outcome at 6 months
LMAS arm suspended

Clinical Outcomes
Outcome

i-gel

LMAS

n = 232

n = 174

Usual
Practice

p
value

n = 209
17.6
21.0 0.58

Admission to hospital %

22.0

Survival to hospital
discharge %

10.3

8.0

9.1 0.73

9.5

6.9

8.6 0.65

Survival to 90 days %

Benger J. BJA 2016;116:2628

Cluster randomised trial of clinical and cost effectiveness

of the i-gel SGA versus tracheal intubation in the initial
airway management of OHCA (AIRWAYS-2)

England
June 2015 to June 2017
1,400 UK paramedics randomised to use the
i-gel or tracheal intubation as their first
advanced airway
9000 patients (10% versus 8%; 0.05; 90%)
At 9 months: 3,121 enrolled
Primary outcome: mRS at discharge or 30 d
DOI 10.1186/ISRCTN08256118

Resuscitation 2016;101:57-64

Cluster-randomised
by EMS agency with
periodic cross over
3000 subjects
85% power for
4.5% difference in
72 h survival

Airway management during CPR:

Summary

No high-quality evidence for any specific

approach to airway and ventilation
management for prehospital cardiac arrest
In practice, stepwise approach to airway
management is common but makes research
challenging
Two ongoing cluster randomised trials:

Airways-2: i-gel versus tracheal intubation

PART: LT versus tracheal intubation
jerry.nolan@nhs.net