What is the role of a respiratory therapist in a Code Blue situation?

Respiratory Therapist Role in Code Blue

The respiratory therapist in a Code Blue is primarily responsible for advanced airway management, including endotracheal intubation, bag-valve-mask ventilation with 100% oxygen, monitoring capnography, and ensuring adequate oxygenation and ventilation throughout the resuscitation. 1

Core Responsibilities During Code Blue

Immediate Airway Management

• Initiate bag-mask ventilation with 100% oxygen at ≥15 L/min as the first-line airway intervention 1
• Use two-handed bag-mask technique when a second provider is available, as this is more effective than single-handed technique 1
• Maintain compression-ventilation ratio of 30:2 to minimize interruptions in chest compressions 1
• Position yourself to optimize airway access while allowing uninterrupted chest compressions 1

Advanced Airway Placement

The RT should follow a systematic airway algorithm when basic maneuvers fail 1:

• First intubation attempt - if unsuccessful proceed to:
• Second intubation attempt - if unsuccessful proceed to:
• First supraglottic airway attempt - if unsuccessful proceed to:
• Second supraglottic airway attempt - if unsuccessful return to:
• Mask ventilation - if inadequate consider cricothyrotomy 1

Limit each intubation attempt to 2 tries per technique to minimize interruptions in chest compressions 1

Post-Intubation Management

• Confirm endotracheal tube placement immediately using capnography 1
• Recommend 6.0-7.0 mm inner diameter ETT for most adult patients 1
• Secure the tube and verify position repeatedly, as secretions and patient movement can cause dislodgement 1
• Ventilate at 8-10 breaths/min once advanced airway is placed 1
• Monitor continuous capnography throughout resuscitation 1
• Avoid hyperventilation, which decreases survival in cardiac arrest 1

Equipment and Monitoring

• Ensure suction equipment is immediately available and functional 1
• Have appropriately sized airway equipment ready, including supraglottic devices and cricothyrotomy kit 1
• Maintain positive pressure ventilation device at bedside 1
• Place viral filter on ventilation circuit if infectious concerns exist 1

Team Positioning and Communication

The respiratory therapist should position themselves at the head of the bed to manage the airway while remaining one of the core team members in the room 1. During COVID-19 or other infectious scenarios, the RT is one of the essential personnel who must wear appropriate PPE and remain in the resuscitation room 1.

Critical Pitfalls to Avoid

• Do not delay intubation in the fully atropinized patient with hypoxia, as this can cause ventricular fibrillation and paradoxical bradycardia 1
• Do not attempt to exchange a functional prehospital supraglottic airway for an ETT during active resuscitation due to aerosolization risk 1
• Do not hyperventilate - this is a common error that decreases survival 1
• Avoid excessive oxygen administration in isolation without addressing ventilation, as this can worsen hypercapnia 1

Special Considerations

High-Risk Airway Scenarios

Certain patients require heightened vigilance from the RT 1:

• Pregnant patients (increased aspiration risk, airway edema, rapid desaturation)
• Obese patients (difficult mask ventilation)
• Patients with sleep apnea (airway obstruction)

Secretion Management

• Regularly aspirate airways using sterile technique, starting immediately after intubation 1
• Excessive secretions may require frequent suctioning to maintain airway patency 1
• Consider nasal intubation over oral route when excessive secretions are present 1

Bronchospasm Management

If severe bronchoconstriction persists despite atropine 1:

• Administer aerosolized albuterol 2.5 mg in 3 mL saline 1
• Consider ipratropium bromide 0.5 mg combined with IV methylprednisolone 125 mg three times daily 1

Documentation and Ongoing Assessment

The RT must continuously assess 2, 3:

• Chest rise with each ventilation
• Oxygen saturation trends
• End-tidal CO2 values
• Airway pressures (watch for sudden elevation suggesting barotrauma) 1
• Tube position and security 1

The respiratory therapist serves as the airway expert during Code Blue, with specialized technical skills in mechanical ventilation management, airway maintenance, and recognition of airway complications that are critical to patient survival 3.