Vocal Cord Position in Cardiac Arrest
In cardiac arrest patients, the vocal cords are typically in a closed or adducted position due to loss of consciousness and muscle tone, which creates a natural protective reflex that can obstruct the airway during resuscitation attempts. 1
Physiologic Basis
The vocal cords in an unconscious cardiac arrest patient assume a position that reflects the loss of voluntary control and the persistence of protective laryngeal reflexes:
The vocal cords remain in persistent apposition (closed position) during the unconscious state, which is the pathophysiologic endpoint of laryngospasm and represents an exaggeration of the normal glottic closure reflex. 1
This closed position creates a significant barrier to ventilation attempts, whether using bag-mask ventilation or attempting endotracheal intubation. 1
The myth that "vocal cords will open before death occurs" is explicitly false—animal studies demonstrate that hypoxia and hypercapnia do not reliably cause vocal cord opening, and the cords can remain closed throughout a fatal arrest. 1
Clinical Implications for Airway Management
The closed vocal cord position during cardiac arrest has critical implications for resuscitation:
Direct visualization of the vocal cords is essential during intubation attempts to confirm that the endotracheal tube passes through them into the trachea, as blind passage is unreliable. 1
The provider must be prepared to resume chest compressions immediately after the tube passes through the vocal cords, minimizing interruption time. 1
Waveform capnography provides 100% sensitivity and 100% specificity for confirming that the tube successfully passed through the vocal cords into the trachea (rather than being deflected into the esophagus by closed cords). 1, 2
Airway Management Strategy
Given the closed vocal cord position in cardiac arrest:
Oropharyngeal airways should be used in unconscious patients with no cough or gag reflex to prevent the tongue from occluding the airway, as the closed vocal cords already create obstruction at the glottic level. 1
Bag-mask ventilation with 100% oxygen should deliver approximately 600 mL tidal volume over 1 second to generate sufficient pressure to overcome the closed glottic resistance and produce chest rise. 1
If attempting endotracheal intubation, limit attempts to minimize interruption of chest compressions, as prolonged attempts with closed vocal cords will compromise coronary and cerebral perfusion. 1
Supraglottic airway devices (laryngeal mask airway, laryngeal tube, esophageal-tracheal tube) may be considered as alternatives, as they do not require passage through the vocal cords. 1
Common Pitfall to Avoid
Do not assume the vocal cords will spontaneously open during cardiac arrest—this dangerous misconception can lead to inadequate airway management and delayed recognition of complete airway obstruction. 1 The closed position persists throughout the arrest unless actively managed with proper airway techniques, direct laryngoscopy for intubation, or placement of supraglottic devices that bypass the glottis entirely.