Should you intubate an adult patient with no known medical history during CPR?

Should You Intubate During CPR?

You should not routinely intubate immediately during CPR; instead, begin with bag-mask ventilation and defer advanced airway placement until the patient fails to respond to initial CPR and defibrillation attempts, unless bag-mask ventilation is inadequate. 1

Initial Airway Management Strategy

The 2020 American Heart Association guidelines establish that both bag-mask ventilation and advanced airways (endotracheal tube or supraglottic airway) are acceptable during CPR, with no high-quality evidence favoring one technique over another. 1 The critical principle is minimizing interruptions to chest compressions, as these interruptions directly impact survival outcomes.

Start with Bag-Mask Ventilation

• All healthcare providers should be trained in effective bag-mask ventilation, which serves as the initial airway management approach during CPR. 1
• Bag-mask ventilation can provide adequate oxygenation and ventilation without interrupting chest compressions. 1
• A stepwise approach to airway management based on patient factors, rescuer skills, and stage of resuscitation is supported by current evidence. 2

Timing of Advanced Airway Placement

When to Defer Intubation

If advanced airway placement will interrupt chest compressions, consider deferring insertion until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation (ROSC). 1 This Class IIb recommendation reflects the critical importance of uninterrupted compressions.

The evidence supporting delayed intubation includes:

• A study found 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
• There is inadequate evidence to define the optimal timing of advanced airway placement, but the priority is clear: minimize compression interruptions. 1

When Immediate Intubation Is Necessary

Proceed with immediate advanced airway placement when:

• Bag-mask ventilation is inadequate to provide effective oxygenation and ventilation. 1
• The airway is obstructed and cannot be managed with basic maneuvers. 1
• Multiple rescuers are available and intubation can be performed without interrupting chest compressions. 1

Choice of Advanced Airway

Supraglottic Airways as an Alternative

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be accomplished successfully without interrupting chest compressions. 1 This makes supraglottic devices particularly attractive during active CPR when minimizing hands-off time is paramount.

• Supraglottic devices are superior to bag-valve-mask for lung ventilation and offer better protection from aspiration. 3
• They can be placed by minimally trained personnel with high success rates (90% within two attempts). 3

Endotracheal Intubation Considerations

If endotracheal intubation is chosen:

• Intubation can be accomplished during ongoing chest compressions, but it frequently causes prolonged interruption of compressions for many seconds. 1
• The provider must weigh the need for minimally interrupted compressions against the need for a definitive airway. 1
• Only experienced operators should attempt intubation during CPR, as inexperienced providers have unacceptably high complication rates. 4

Critical Post-Placement Requirements

Mandatory Confirmation with Capnography

Continuous waveform capnography is recommended (Class I, Level of Evidence A) as the most reliable method of confirming and monitoring correct placement of an endotracheal tube. 1 This is non-negotiable:

• Waveform capnography must be used for all intubations and continuously for all patients dependent on an artificial airway. 5, 4
• Failure to use capnography contributes to more than 70% of ICU airway-related deaths. 5
• Physical examination alone (chest rise, breath sounds) is insufficient and must be supplemented with capnography. 1

Ventilation Strategy During CPR

Once an advanced airway is in place:

• Provide maximum feasible inspired oxygen during CPR. 2
• Avoid hyperventilation, which may worsen outcomes and cause cerebral vasoconstriction. 6
• Use waveform capnography to guide ventilation adequacy. 2

Common Pitfalls to Avoid

Prolonged Intubation Attempts

• Never persist with multiple failed intubation attempts that interrupt chest compressions. 1
• Have a backup strategy ready (supraglottic airway or return to bag-mask ventilation). 1
• The most experienced available operator should manage difficult airways. 1

Inadequate Skill Level

• Healthcare providers must maintain their knowledge and skills through frequent practice and retraining. 1, 4
• It may be helpful for providers to master one primary method of airway control with a clear backup strategy. 1

Delaying CPR for Airway Management

• Chest compressions take priority over advanced airway placement. 1
• The CPR sequence should begin with compressions rather than ventilation to minimize time to first compression. 1

Algorithm for Decision-Making

1. Begin CPR with chest compressions immediately. 1
2. Provide ventilation with bag-mask device while compressions continue. 1
3. Assess adequacy of bag-mask ventilation:
   • If adequate → continue bag-mask ventilation until patient responds to CPR/defibrillation or achieves ROSC. 1
   • If inadequate → proceed to advanced airway. 1
4. If advanced airway needed, choose based on:
   • Operator skill level (supraglottic airway if less experienced). 1, 3
   • Ability to place without interrupting compressions (favors supraglottic airway). 1
   • Patient factors (aspiration risk, airway obstruction). 1
5. Confirm placement immediately with waveform capnography. 1, 5, 4
6. Continue CPR with minimal interruptions. 1