What is the preferred method for securing the airway in cardiac arrest, i-gel or intubation?

Airway Management in Cardiac Arrest: i-gel vs Intubation

Either an i-gel supraglottic airway device or tracheal intubation can be used as the initial advanced airway management strategy during cardiac arrest, as neither approach has demonstrated superiority in improving survival or neurological outcomes. 1

Evidence Overview

The 2015 and 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science guidelines provide clear recommendations on airway management during cardiac arrest:

• Both supraglottic airways (SGAs) like the i-gel and tracheal intubation are acceptable options for advanced airway management during CPR 1
• The choice between them should be based on provider skill level and training 1
• Waveform capnography is essential for confirming and monitoring tube placement 1

Comparative Effectiveness

The AIRWAYS-2 randomized clinical trial (2018) directly compared i-gel to tracheal intubation in 9,296 out-of-hospital cardiac arrest patients:

• No significant difference in good neurological outcomes (modified Rankin Scale 0-3) at 30 days: 6.4% in i-gel group vs 6.8% in intubation group 2
• These findings remained consistent at 3 and 6 months follow-up 3
• Initial ventilation success was higher with i-gel (87.4% vs 79.0%) 2
• No significant differences in regurgitation or aspiration rates between groups 2

Practical Considerations

Advantages of i-gel:

• Higher initial ventilation success rate 2
• Faster insertion time, especially for less experienced providers 4
• Allows continuous chest compressions without interruption in 74% of cases 5
• Requires less training to maintain proficiency 1

Advantages of Tracheal Intubation:

• Better airway protection in cases of bronchoaspiration 6
• More definitive airway control for prolonged resuscitation 1
• Preferred in specific scenarios like bronchoaspiration 6

Decision Algorithm

1. Assess provider skill level:

   • If provider has extensive intubation experience and can perform quickly without interrupting compressions → Consider intubation
   • If provider has limited intubation experience or infrequent practice → Use i-gel

2. Consider specific patient factors:

   • Known or suspected aspiration → Favor intubation if provider skilled 6
   • Need for prolonged ventilation → Favor intubation
   • Need to minimize interruptions to compressions → Favor i-gel 5

3. For either approach:

   • Confirm placement with waveform capnography 1
   • Avoid prolonged attempts that interrupt chest compressions 1
   • Be prepared to switch to alternative airway strategy if first attempt fails

Common Pitfalls to Avoid

• Prolonged intubation attempts: Never interrupt chest compressions for more than 10 seconds for airway management
• Unrecognized esophageal intubation: Always confirm tube placement with waveform capnography 1
• Overventilation: Maintain 6-8 breaths per minute after advanced airway placement 6
• Skill degradation: Providers should regularly practice the airway technique they're most likely to use in cardiac arrest

In summary, both i-gel and tracheal intubation are acceptable approaches for airway management during cardiac arrest. The decision should primarily be based on provider skill level and specific patient circumstances rather than an expectation of improved survival with either technique.