Should we intubate a pulseless patient undergoing Cardiopulmonary Resuscitation (CPR)?

Intubation During CPR for Pulseless Patients

You should NOT immediately intubate a pulseless patient during CPR; instead, prioritize high-quality chest compressions and defibrillation first, then consider deferring advanced airway placement until after initial resuscitation attempts fail or ROSC is achieved. 1

Primary Approach: Bag-Mask Ventilation First

• Bag-mask ventilation is acceptable and should be the initial airway management strategy during CPR for pulseless patients. 1
• All healthcare providers must be trained in delivering effective oxygenation and ventilation with bag-mask devices, as this serves as both primary and backup airway strategy. 1
• Bag-mask ventilation avoids the significant interruptions in chest compressions that frequently occur during intubation attempts. 1

The Critical Problem with Early Intubation

• Endotracheal intubation during CPR is frequently associated with interruption of chest compressions for many seconds, which directly compromises outcomes. 1
• The evidence shows that minimally interrupted chest compressions are more important than securing an advanced airway early in the resuscitation. 1
• A recent study demonstrated that delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with witnessed VF/pulseless VT. 1

When to Consider Advanced Airway Placement

If advanced airway placement will interrupt chest compressions, defer insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb recommendation). 1

Timing Considerations:

• In a registry study of 25,006 in-hospital cardiac arrests, earlier time to invasive airway (<5 minutes) was NOT associated with improved ROSC, though it was associated with improved 24-hour survival. 1
• In urban out-of-hospital settings, intubation achieved in <12 minutes was associated with better survival than intubation achieved in ≥13 minutes. 1
• The optimal timing of advanced airway placement in relation to other interventions during cardiac arrest remains inadequately defined by evidence. 1

Alternative: Supraglottic Airways

• Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be accomplished successfully without interrupting chest compressions. 1
• Supraglottic airways avoid the prolonged interruptions typically associated with endotracheal intubation attempts. 1

The Decision-Making Algorithm

Step 1: Confirm Cardiac Arrest

• If the patient is unconscious/unresponsive with absent or abnormal breathing (gasping), and no definite pulse is felt within 10 seconds, assume cardiac arrest. 1

Step 2: Immediate Actions (Do NOT intubate yet)

• Begin high-quality chest compressions immediately (rate 100-120/min, depth at least 2 inches/5 cm). 2
• Provide bag-mask ventilation with appropriate compression-to-ventilation ratio. 1
• Prepare defibrillator and deliver shocks if indicated for VF/pulseless VT. 1, 2

Step 3: Reassess After Initial Interventions

• After initial CPR cycles and defibrillation attempts (if applicable), reassess the situation. 1
• Only consider advanced airway if:
  • Patient fails to respond to initial CPR and defibrillation attempts 1
  • Bag-mask ventilation is inadequate 1
  • You can place the airway WITHOUT interrupting chest compressions 1

Step 4: If Intubation Is Necessary

• Brief attempts should be made to intubate, but these procedures should NOT cause undue delay in continuing chest compressions. 1
• Consider supraglottic airway as first choice if it can be placed without stopping compressions. 1
• Use continuous waveform capnography immediately after placement to confirm correct positioning (Class I recommendation). 1

Critical Pitfalls to Avoid

• Never prioritize intubation over chest compressions - the primary task is to maintain circulation, not to secure an airway. 1
• Do not allow intubation attempts to cause interruptions in chest compressions exceeding 10 seconds. 1
• Avoid the mindset that "the patient needs a tube" - they need perfusion first. 1
• Do not attempt intubation if you cannot do so while compressions continue, unless bag-mask ventilation is completely failing. 1

Post-Advanced Airway Management

• Once an advanced airway is placed, deliver continuous chest compressions without pausing for ventilations. 1
• Provide ventilations at 8-10 breaths per minute, avoiding excessive ventilation. 1, 2
• Monitor placement continuously with waveform capnography (target PETCO2 >10 mmHg, ideally >20 mmHg). 1, 2