airway management during cpr: tracheal intubation is better ......tracheal intubation during cpr:...
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Airway Management during CPR: Tracheal intubation is better than
supraglottic airway
Jerry Nolan Royal United Hospital Bath, UK
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Tracheal intubation during CPR: advantages over SGA Enables uninterrupted chest compressions
and minimises ‘no flow’ time Enables most effective ventilation
particularly when lung compliance is poor. Least likely airway to be dislodged? Minimises gastric inflation and protects
against aspiration Evidence for improved outcome with
tracheal intubation compared with SGA
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ALS before and after intubation
Kramer-Johansen J. Resuscitation 2006;48:61-9
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Quality of resuscitation before and after tracheal intubation
N = 119 Before intubation
After intubation
Difference (mean %, 95% CI)
Chest compressions (% of time)
39 ± 20% 59 ± 18% 20 (16-24)
Compressions min-1 47 ± 25 71 ± 23 24 (19-29) Ventilations min-1 5.6 ± 3.7 14 ± 5.0 8.7 (7.6-9.8)
Kramer-Johansen J. Resuscitation 2006;48:61-9
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Regurgitation and aspiration: out-of-hospital cardiac arrest (OHCA)
Regurgitation occurs in 20-30% of OHCAs Regurgitation associated with odds ratio
of survival of 0.5 (0.28 – 0.89) Early-onset pneumonia in 2/3 of OHCA
patients admitted to ICU
Simons RW. Resuscitation 2007;74:4267-31 Virkkunen I. Acta Anaesthesiol Scand 2007;51:202-5 Perbet S. AJRCCM 2011;184:1048-54
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Intubation success: cardiac arrest Study N Intubator Success (%)
Bradley, 1998 57 EMT 49 Sayre, 1998 103 EMT 51 Rumball, 2004 250 EMT 70 Rabitsch, 2003 83 Physician 94 Stiell, 2004 3848 Paramedic 93.7 Deakin, 2010 368 Paramedic 83.8 Lyon, 2010 628 Paramedic 91.2 Stiell, 2011 (ROC) 7651 EMS 89.3 Hubble, 2010 +++ All 91.2
Hubble MW. Prehosp Emerg Care 2010;14:377–401
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Meta-analysis of prehospital airway techniques in cardiac arrest
Supraglottic airway
Insertion Success (%)
95% CI
Combitube 87.4 77.9 – 93.2 LMA 86.3 60.7 – 96.3 Laryngeal Tube 96.0 41.7 – 99.9 Tracheal intubation 91.1 88.0 – 93.4
Hubble MW. Prehosp Emerg Care 2010;14:515-530 Hubble MW. Prehosp Emerg Care 2010;14:377-401
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2012, 20:84
Insertion success in 347 patients
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2012, 20:84
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Advanced Airway device (n=10,455)
Insertion n (%)
Tracheal tube 8487 (81.2%) Supraglottic airway 1968 (18.8%)
Laryngeal tube 909 (63.0%) Combitube 296 (20.5%)
LMA 239 (16.6%)
Resuscitation 2012;83:1061-6
85% received successful Tracheal Tube or SGA alone
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Wang HE. Resuscitation 2012;83:1061-6
Survival to discharge with good neurology: TT 4.7% vs. SGA 3.9%
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Tanabe S. J Emerg Med 2013;44:389-97
All Japan 2005 – 2007 Advanced airway devices used in 138,248 of 318,141 cardiac arrests
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Resuscitation 2012;83:313-9
Korea
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% change carotid flow compared with tracheal tube
Resuscitation 2012;83:1025-30
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Just finished recruiting (28 Feb 2013) 184 paramedics randomised and trained 600 cardiac arrests Neurological outcome at 6 months Will inform larger RCT
2013;3:e002467
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Tracheal intubation during CPR: advantages over SGA: summary
Minimises ‘no flow’ time Enables most effective ventilation Least likely airway to be dislodged Minimises gastric inflation Improved outcome compared with SGA
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Airway management during cardiac arrest
Optimal technique is unknown Likely to depend on the skill of the operator Many cardiac arrests involve multiple
airways Timing may critical, e.g. delay intubation
until after ROSC Must not compromise high-quality CPR Large randomised trial is essential
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