What is an advanced airway in CPR

Introduction

In the United States, the incidence of out-of-the hospital cardiac arrest [OHCA] is 76.5 per 100,000 with 10.6% of patients surviving their initial hospitalization and 8.2% recovering with good functional status. 1.2% of adults admitted to US hospitals experience in-hospital cardiac arrest [IHCA]. 25.8% of those patients are discharged from the hospital and 82% of those have good functional outcomes [, ]. Early cardiopulmonary resuscitation [CPR] and defibrillation are important treatment steps; however, adequate oxygenation and ventilation are also important in preventing organ damage from hypoxia. Recent trials have evaluated the impact of the choice of airway management and the timing of airway management strategies on the survival to hospital discharge and neurological outcomes. This review presents a summary of the recent literature and the most recent guidelines regarding the changes in airway management during cardiopulmonary resuscitation for adult cardiac arrest as well as for pediatric and neonatal resuscitation. Many of the studies were applied to OHCA setting, and the recommendations for IHCA are extrapolated from OHCA studies.

Perioperative cardiac arrest and cardiac arrest outside the operating room present challenges to anesthesiologists and other clinicians who provide airway management. There are few studies that emphasize the specifics of airway management during perioperative cardiac arrest and outside the operating room cardiac arrest. As a result, clinicians providing airway management should refer to the American Heart Association [AHA] guidelines when performing advanced airway management during CPR.

Search Strategy:

The literature search included the PubMed, EMBASE, and Cochrane database between 2016 and 2021. Included articles focused on airway management during cardiopulmonary resuscitation in the adult, pediatric, and neonatal population, and in the pregnant patient. Other keywords used included advanced airway, supraglottic airway and endotracheal intubation in OHCA and IHCA. Included articles were published guidelines, systematic reviews, randomized controlled trials, and observational trials. Case reports, conference proceedings, editorials, animal studies, manikin studies, and non-English articles were excluded. A total of 840 articles were found after removing duplicates. Screening resulted in the inclusion of 360 articles. Upon title and abstract review, 134 articles met inclusion criteria for full text review.

Airway management and the Cardiopulmonary Resuscitation Guidelines

Airway management and ventilation are crucial components of advanced cardiac life support [ACLS]. Airway management during cardiopulmonary resuscitation [CPR] provides adequate oxygenation and ventilation, prevents hypoxic injury, and increases the chances of overall and neurological survival. In the 2019 updated guidelines, recommendations were updated related to the use of advanced airway devices, the need for training, and the need to master an advanced airway strategy in addition to a second [backup] strategy. The guidelines also emphasized the use of capnography [•]. The 2019 and 2020 focused updates on ACLS guidelines emphasized that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting while minimizing interruptions in chest compression [••]. Placement of an advanced airway device can be delayed until after 2 rounds of chest compressions are completed if bag mask ventilation is adequate. The 2020 BLS guidelines simplified rescue breathing to be 10 breaths per minutes or every 6 s while using either a supraglottic airway [SGA] or an endotracheal tube [ETT]. The use of an SGA is prioritized in situations where clinicians have received minimal training in airway management or when the intubation success rate is low [Fig. ] [••]. In 2021, the international consensus on CPR and emergency cardiovascular care [ECC] released an updated summary on advanced life support, including special situations such as airway management in drowning, use of barrier devices, and the performance of CPR in the prone position [••].

Fig. 1

Representation of Advanced Life Support recommendations for the use of advanced airways during cardiopulmonary resuscitation. EMS, emergency medical services. Reprinted with Permission from Panchal et al. 2020

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Airway Management for Perioperative Cardiac Arrest

The reported incidence of perioperative cardiac arrest is 4.3–19.7 per 10,000 anesthetics that involve cardiac and non-cardiac surgeries [••]. In a report using the National Anesthesia Clinical Outcomes Registry [NACOR], the analysis of 1,691,472 anesthetics included procedures performed in the radiology and gastrointestinal suites, and reported the incidence to be 5.6 cardiac arrests per 10,000 anesthetics []. Many risk factors have contributed to the incidence of perioperative cardiac arrest, including anesthesia for emergency procedures, trauma patients, and hemodynamically unstable patients. Airway-related cardiac arrest can result from post-intubation hemodynamic instability, difficult airway and hypoxia, or during emergence and extubation []. Other airway-related causes of cardiac arrests include respiratory depression during Monitored Anesthesia Care [MAC] or conscious sedation. In all situations, perioperative cardiac arrest can contribute to the complexity and difficulty of airway management during CPR. During perioperative cardiac arrest related to airway management, if an advanced airway is not in place, the clinician managing the airway should revert back to the basics of ACLS and consider an advanced airway management strategy [••]. The basics of advanced airway management during cardiac arrest include bag-mask ventilation or placement of an advanced airway management device [either an SGA or ETT] based on the skills of the airway manager.

Airway Techniques and Devices during Cardiopulmonary Resuscitation

Rescue Breathing

Rescue breathing provides oxygenation and ventilation to a patient who is unconscious and not spontaneously breathing. Rescue breathing can be performed via mouth-to-mouth, with or without a barrier, or via bag mask ventilation [BMV]. Visible chest rise is required to confirm the appropriate technique while avoiding excessive ventilation. Rescue breathing should be delivered as one breath every 6 s [or 10 breaths per minute]. Once CPR is started, two ventilations should be initiated after completing 30 compressions [, ]. Once return of spontaneous circulation [ROSC] is obtained, rescue breaths should continue at the same rate, if the patient is not spontaneously breathing, while performing pulse checks every 2 min. Per the 2020 updated AHA guidelines, either BMV or an advanced airway strategy may be considered during CPR to provide rescue breathing for adult cardiac arrest in any setting, based on the provider’s skills and the situation [••].

Advanced Airway Management

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 known]. [Fig. ]. In settings where providers receive minimal training for endotracheal tube placement or the tracheal intubation success rate is low, then SGA placement would be preferred. 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.

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. Multiple recent studies have compared the use of an SGA versus an ETT and found no difference in survival or neurological outcomes between the two devices [, ]. As a result, the 2020 updated guidelines provided recommendations to use either technique during CPR in any setting [OHCA or IHCA]. In a recent observational study including 14,969 patients, use of an early advanced airway strategy in the form of endotracheal intubation [ETI] was correlated with favorable neurological outcomes []. Timing of advanced airway placement has been evaluated in 2 recent studies. Okubo et al. performed a secondary analysis of the Pragmatic Airway Resuscitation Trial [PART] to evaluate the impact of timing of advanced airway placement on patient outcome. In this analysis, the authors evaluated different cohorts based on timing of advanced airway placement and divided them into 4 cohorts [0-