Advanced airway management, such as endotracheal intubation (ETI) or supraglottic airway (SGA) insertion, is a crucial aspect of cardiac arrest resuscitation (Benoit et al., 2015). Recent recommendations from the American Heart Association and the International Consensus on Cardiopulmonary Resuscitation highlight the significance of advanced airway strategies in both out-of-hospital and in-hospital cardiac arrest scenarios (Mohamed, 2022).
The choice of whether to place an endotracheal tube or a supraglottic airway for oxygenation and ventilation should depend on the level of training of the provider as well the success rate of endotracheal intubation; if personnel have minimal training or low rates of success with endotracheal tube intubation, then perhaps a supraglottic airway should be substituted. In an in-hospital setting, an advanced airway should be used by expert providers trained in airway management. Many of the airway recommendations for airway management in IHCA are extrapolated from the OHCA studies, due to the limited in-hospital studies on advanced airway management in cardiac arrest.
The updated ACLS guidelines released in 2020 emphasized that clinicians should master one advanced airway technique as well as a second technique as a backup strategy.
Studies have indicated that early placement of an advanced airway within 5 minutes of collapse is linked to improved outcomes in cases of cardiac arrest (Morley, 2011). In a recent study, the delay in advanced airway placement was associated with negative outcomes in cardiac arrest (Fukuda 2021)
While the selection of airway management methods, such as ETI, SGA, or bag-mask ventilation, is a topic of debate, the primary objective during cardiac arrest is to ensure adequate oxygenation and ventilation without disrupting resuscitation efforts (Smith & Yeung, 2018). Despite some studies suggesting a negative correlation between advanced airway placement and survival in out-of-hospital cardiac arrest cases, the consensus supports the use of advanced airway management for better outcomes (Chase et al., 2014).
Furthermore, the utilization of advanced airway management has been associated with enhanced neurologic outcomes and survival rates in individuals experiencing out-of-hospital cardiac arrest (Hasegawa et al., 2013). Although there are ongoing discussions regarding the most effective airway management techniques, there is a consensus that advanced airway interventions are essential for optimizing resuscitation efforts and improving patient outcomes during cardiac arrest scenarios (Rijal, 2018). In a recent study (n=14,969), use of an early advanced airway strategy in the form of endotracheal intubation (ETI) was correlated with favorable neurological outcomes, CPC 1–2 at 1 month after OHCA (Nakagawa 2021). Additionally, in an observational study of a nationwide cohort in Japan, early endotracheal intubation was associated with improved survival for a non-shockable rhythm (but not for a shockable rhythm) when compared to delayed endotracheal intubation (Okubo 2021).
In conclusion:
Advanced airway management is a critical element of cardiac arrest resuscitation, with studies supporting its association with improved survival rates and neurologic outcomes. While the specific choice of airway techniques may vary, ensuring timely and effective airway management is crucial for increasing the likelihood of successful resuscitation in both out-of-hospital and in-hospital cardiac arrest situations.
References:
- Benoit, J., Prince, D., & Wang, H. (2015). Mechanisms linking advanced airway management and cardiac arrest outcomes. Resuscitation, 93, 124-127.
https://doi.org/10.1016/j.resuscitation.2015.06.005
- Chase, D., Salvucci, A., Marino, R., Shedlosky, R., Merman, N., & Hadduck, K. (2014). Effect of airway management and impedance threshold device on circulation, survival and neurological outcome in adult out-of-hospital cardiac arrest. Open Journal of Emergency Medicine, 02(01), 12-18.
https://doi.org/10.4236/ojem.2014.21003
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https://doi.org/10.1001/jama.2012.187612
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https://doi.org/10.1007/s40140-022-00527-z
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https://doi.org/10.1186/cc10552
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- Okubo M, Komukai S, Izawa J, et al. Timing of Prehospital Advanced Airway Management for Adult Patients With Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan. J Am Heart Assoc. 2021;10(17):e021679.
- Rijal, S. (2018). Use of bag-mask ventilation for cardiopulmonary resuscitation: do we need more evidence for low resource setting?. jgpeman, 5(7), 24-26.
https://doi.org/10.59284/jgpeman113
- Smith, C. and Yeung, J. (2018). Airway management in cardiac arrest—not a question of choice but of quality?. Resuscitation, 133, A5-A6.
https://doi.org/10.1016/j.resuscitation.2018.10.009