When intubating a newborn in cardiac arrest, should chest compressions be paused while inserting the endotracheal tube?

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Last updated: October 24, 2026 • View editorial policy

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Should Chest Compressions Be Paused During Endotracheal Intubation in Newborn Cardiac Arrest?

No, chest compressions should NOT be routinely paused during endotracheal intubation attempts in newborn cardiac arrest, though brief interruptions may be necessary for tube passage through the vocal cords.

The Core Principle: Minimize Interruptions

The fundamental issue is that chest compressions are critical for maintaining coronary perfusion pressure during neonatal cardiac arrest, and interruptions directly compromise this. The guidelines consistently emphasize that interruptions should be minimized to the absolute minimum necessary 1, 2.

What the Guidelines Actually Say

The 2015 AHA Neonatal Resuscitation Guidelines 2 state that:

  • Compressions and ventilations should be coordinated to avoid simultaneous delivery
  • The 3:1 compression-to-ventilation ratio should be maintained with pauses after every 3rd compression for ventilation
  • Chest compressions are indicated when heart rate remains <60/min despite adequate ventilation, ideally via endotracheal tube

The guidelines recommend intubation when chest compressions are performed 2, 1, 2, but they do not explicitly mandate stopping compressions during the intubation attempt itself.

Practical Algorithm for Intubation During Compressions

Before the Attempt:

  • Ensure optimal positioning and equipment preparation - have the tube ready at hand, laryngoscope checked, suction available
  • The intubator should be fully prepared before any pause is considered
  • Consider having the most experienced provider perform the intubation 3

During the Attempt:

  1. Compressions continue while the intubator positions and prepares
  2. Brief pause ONLY for visualization and tube passage - ideally <10 seconds (extrapolated from adult/pediatric guidelines 4)
  3. Resume compressions immediately once tube passes through vocal cords
  4. Do not pause for tube confirmation - use continuous waveform capnography while compressions continue 2, 1

If Intubation Fails:

  • Do not make repeated prolonged attempts - consider a supraglottic airway device (laryngeal mask) as an alternative 5, 6
  • Recent evidence shows supraglottic airways can be placed in 7 seconds without interrupting compressions versus 16.5 seconds for intubation 6
  • The 2025 guidelines now support supraglottic airway use during compressions when intubation is unsuccessful 7, 5

Critical Caveats

The Ventilation Paradox

There's an inherent tension here: neonatal cardiac arrest is almost always due to respiratory failure 1, 2, 1, making effective ventilation paramount. However, chest compressions "compete with effective ventilation" 1, 2. This is why:

  • Ensure bag-mask ventilation is optimized BEFORE starting compressions 1, 2
  • The 3:1 ratio with coordinated pauses exists specifically to maximize ventilation 2
  • Once intubated, continue the 3:1 ratio with brief pauses for ventilation 2

Experience Matters

Intubation success rates vary dramatically by experience 3:

  • Residents: 24% success, mean 49 seconds
  • Fellows: 78% success, mean 32 seconds
  • Consultants: 86% success, mean 25 seconds

If the intubator is inexperienced, strongly consider using a supraglottic airway instead to avoid prolonged compression interruptions 5, 6.

Monitoring During the Attempt

  • Infants frequently deteriorate during intubation attempts, especially if heart rate and oxygen saturation are already low 3
  • Use continuous waveform capnography to confirm tube placement without interrupting compressions 2, 1
  • Clinical assessment alone takes longer and is less reliable 3

The 2025 Evolution

The most recent 2025 guidelines 7, 5 represent a shift toward accepting supraglottic airways during compressions when intubation is difficult, acknowledging that maintaining compressions may be more important than achieving endotracheal intubation at all costs. This is supported by manikin data showing supraglottic devices can be placed rapidly without interrupting compressions 6.

Bottom Line for Clinical Practice

Prepare thoroughly, pause briefly only for tube passage (<10 seconds), and resume compressions immediately. If intubation is taking too long or failing, switch to a supraglottic airway rather than making repeated attempts that interrupt compressions. The goal is effective ventilation with minimal interruption to chest compressions, not perfect airway management at the expense of perfusion.

References

6
Research

Rapid Airway Placement Without Pausing Chest Compressions: Supraglottic Airway Versus Endotracheal Intubation.

Pediatrics international : official journal of the Japan Pediatric Society, 2026

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.