Airway managment

during CPRStefano Malinverni MD

CHU Saint Pierre

Conflicts of interests

• I am a believer

of ET

ET DURING CPR

Advanced airway management

• Minimize complications

• Minimize no flow time

• Minimize interruptions of chest compressions

• Protect against inhalation

• Guarantee oxygenation despite altered chest

compliance and pulmonary epithelium

• Increase cardiac output

• Increase chances of ROSC and intact neurological

survival

Gold standard?

Theoretical advantages

• Reduces no flow time by suppressing ventilation

associated pauses

• Reduces the number of chest compression pauses

• Reduces inhalation risk

• Reduces gastric insufflation

• Less risks of airway displacement

• Allows for an impedance valve use

• Allows continuous ETCO2 monitoring

• Endotracheal intubation and

laryngeal mask both

significantly reduce NO-flow

time by allowing continuous

chest compressions

• Endotracheal intubation and

laryngeal mask both

significantly reduce NO-flow

time by allowing continuous

chest compressions

Endotracheal tube

placement in practice

Endotracheal tube placement

in theory (in the OR)

• Up to 9

intubation

attempts during

ALS with a

median of 2

attempts per ALS.

• The median time of

chest compression

interruption during

the first intubation

attempt was 47

seconds.

• The median total time

of chest compressions

interruptions to place

an endotracheal tube

was 110 seconds.

Failure1st attempt No failure

• 85% of endotracheal tube

placements needed less than 2

attempts

• 7.5% of endotracheal tube

placements needed 3 or more

attempts

• 7.5% of attempts never

succeeded

TUBE

TUBE

IS SCIENTIFIC EVIDENCE IN

FAVOUR OF OR AGAINST

ROUTINE ENDOTRACHEAL

INTUBATION DURING CPR?

TUBE

TUBE

• PARAMEDIC based system with obligation to

admit to hospital every cardiac arrest.

ROSC

LT

Survival with

CPC 1-2

ET vs Bag Valve mask(propensity score matched)

ET placement within 15 min vs after• ROSC 59.3 vs 57.8 . Survival with CPC 1-2 13.6 vs 10.6

• Survie sortie hôpital RR 0.84

• Outcome neurologiquement favorable RR 0.78

• ROSC 59.3%: (BMV) vs 57.8% (immediate ET placement) RR 0.96

• Hospital discharge: 19.4% (BMV) vs 16.3% (immediate ET placement)

RR 0.84

• Favourable neurological outcome: 13.6% (BMV) vs 10.6% (immediate

ET placement) RR 0.78

0

5

10

15

BMV ETI

CPC 1-2

BMV

ETI13.610.6

Supraglottic

devices?

TUBE

TUBE

•Survival with favourable

neurological outcome

• Theoretical advantages of ET placement

but

• Empirical scientific evidence is not in

favour of routine ET placement during

cardiac arrest.

ER doctor

TUBE

TUBE

ET placement only if experienced, without

any interruption and after implementing

high quality CPR and early defibrillation.

•ROSC

•Survie jusqu’à l’admission

SGD réduisent la probabilité

d’outcome favorable

Toujours confirmer placement

du tube par capnographie

• Intubation trachéale n’a jamais démontré une supériorité par rapport au masque ballon pendant la CPR

• Si décision de placement de TE:• Sans pauses de massage• Par operateur expérimenté• Toujours confirmé par capnographie• Aide par vidéo-laryngoscopie?

• Preuves de infériorité des moyens Supra-glottiques• A garder pour échecs ventilation masque

ballon / échecs intubation