Part 7.1: Adjuncts for Airway Control and Ventilation V-53 practice is essential. 2 It is important to remember that there occurrence of complications should be monitored closely. It is no evidence that advanced airway measures improv s acceptable for healthcare professionals to use the LMa as survival rates in the setting of prehospital cardiac arrest. an alternative to the endotracheal tube for airway manage ment in cardiac arrest(Class Ila) Esophageal-Tracheal Combitube The advantages of the Combitube compared with the face Endotracheal Intubation mask are similar to those of the endotracheal tube: isolation The endotracheal tube keeps the airway patent, permits of the airway, reduced risk of aspiration, and more reliable suctioning of airway secretions, enables delivery of a high ventilation. The advantages of the Combitube over the concentration of oxygen, provides an alternative route for the endotracheal tube are related chiefly to ease of training. 2.2 administration of some drugs, facilitates delivery of a selected Ventilation and oxygenation with the Combitube compare tidal volume, and with use of a cuff may protect the airway favorably with those achieved with the endotracheal tube from aspiration. 53 In 5 randomized controlled trials involving both in-hospi Endotracheal intubation attempts by unskilled providers and out-of-hospital adult resuscitation, providers with all can produce complications, such as trauma to the oropharynx, levels of experience were able to insert the Combitube and interruption of compressions and ventilations for unaccept deliver ventilation that was comparable to that achieved with ably long periods, and hypoxemia from prolonged intubation endotracheal intubation(LOE 2).21.26-29 Thus, it is acceptable attempts or failure to recognize tube misplacement or dis for healthcare professionals to use the Combitube as an placement. Providers who perform endotracheal intubation alternative to the endotracheal tube for airway management in require adequate initial training and either frequent experi- cardiac arrest( Class lla) ence or frequent retraining(Class I). EMS systems that Fatal complications may occur with use of the Combitube provide prehospital intubation should establish a process for esophagus or trachea is identified incorrectly. For this reason( Class Ila) onfirmation of tube placement is essential. Other possible Indications for emergency endotracheal intubation are(1) plications related to the use of the Combitube are the inability of the rescuer to adequately ventilate the uncon- esophageal trauma, including lacerations, bruising, and sub- cious patient with a bag and mask and(2)the absence of cutaneous emphysema(LOE 230, LOE 525.3). airway protective reflexes(coma or cardiac arrest). The rescuer must have appropriate training and experience in Laryngeal Mask Airway endotracheal intubation The LMA provides a more secure and reliable means of During CPR we recommend that rescuers minimize the ventilation than the face mask. 32,33 Although the LMa doe number and duration of interruptions in chest compressions, not ensure absolute protection against aspiration, studies have with a goal to limit interruptions to no more than 10 seconds shown that regurgitation is less likely with the LMA than except as needed for interventions such as placement of an with the bag-mask device and that aspiration is uncommon. way. Interruptions needed for intub When compared with the endotracheal tube, the LMa pro- minimized if the intubating rescuer is prepared to begin the vides equivalent ventilation 3.34 successful ventilation during intubation attempt(ie, insert the laryngoscope blade with the CPR is reported in 71.5% to 97% of patients. 22,25.35-38 tube ready at hand) as soon as the compressing rescuer pauses Training in the placement and use of an LMA is simpler compressions. The compressions should be interrupted only than that for endotracheal intubation because insertion of the as long as the intubating rescuer needs to visualize the vocal LMA does not require laryngoscopy and visualization of the cords and insert the tube. The compressing rescuer should be vocal cords. The LMA may also have advantages over the prepared to resume chest compressions immediately after the endotracheal tube when access to the patient is limited, 39.40 tube is passed through the vocal cords. If more than one there is a possibility of unstable neck injury, I or appropriate intubation attempt is required, the rescuers should provide a positioning of the patient for endotracheal intubation is period of adequate ventilation and oxygenation and chest impossible. compressions between attempts Results from multiple high-level studies in anesthetized If endotracheal intubation is performed for the patient with patients that compared the LMa with endotracheal intubation a perfusing rhythm, use pulse oximetry and ECG monitoring (LOE 2)39,42-46 and multiple additional studies that compared continuously during intubation attempts and interrupt the the LMa with other airways or ventilation techniques (Loe attempt to provide oxygenation and ventilation if needed. 2)247-52 support the use of the LMA in controlling the airway Even when the endotracheal tube is seen to pass through in a variety of settings by nurses, respiratory therapists, and the vocal cords and tube position is verified by chest EMS personnel, many of whom had not previously used this expansion and auscultation during positive-pressure ventila- devic tion, rescuers should obtain additional confirmation of place After successful insertion a small proportion of patients ment using an end-tidal CO2 or esophageal detection devic cannot be ventilated with the LMA. 2.3With this in mind, it (Class IIa).54 There is a high risk of tube misplacement, is important for providers to have an alternative strategy for displacement, or obstruction, 16 20 especially when the patient management of the airway. Providers who insert the LMA is moved, 55 No single confirmation technique, including should receive adequate initial training and should prad clinical signs or the presence of water vapor in the tube, 57is insertion of the device regularly. Success rates and the completely reliable Techniques to confirm endotracheal tubepractice is essential.23 It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of prehospital cardiac arrest. Esophageal-Tracheal Combitube The advantages of the Combitube compared with the face mask are similar to those of the endotracheal tube: isolation of the airway, reduced risk of aspiration, and more reliable ventilation. The advantages of the Combitube over the endotracheal tube are related chiefly to ease of training.2,24 Ventilation and oxygenation with the Combitube compare favorably with those achieved with the endotracheal tube.25 In 5 randomized controlled trials involving both in-hospital and out-of-hospital adult resuscitation, providers with all levels of experience were able to insert the Combitube and deliver ventilation that was comparable to that achieved with endotracheal intubation (LOE 2).21,26 –29 Thus, it is acceptable for healthcare professionals to use the Combitube as an alternative to the endotracheal tube for airway management in cardiac arrest (Class IIa). Fatal complications may occur with use of the Combitube if the position of the distal lumen of the Combitube in the esophagus or trachea is identified incorrectly. For this reason confirmation of tube placement is essential. Other possible complications related to the use of the Combitube are esophageal trauma, including lacerations, bruising, and sub￾cutaneous emphysema (LOE 230; LOE 525,31). Laryngeal Mask Airway The LMA provides a more secure and reliable means of ventilation than the face mask.32,33 Although the LMA does not ensure absolute protection against aspiration, studies have shown that regurgitation is less likely with the LMA than with the bag-mask device and that aspiration is uncommon. When compared with the endotracheal tube, the LMA pro￾vides equivalent ventilation33,34; successful ventilation during CPR is reported in 71.5% to 97% of patients.22,25,35–38 Training in the placement and use of an LMA is simpler than that for endotracheal intubation because insertion of the LMA does not require laryngoscopy and visualization of the vocal cords. The LMA may also have advantages over the endotracheal tube when access to the patient is limited,39,40 there is a possibility of unstable neck injury,41 or appropriate positioning of the patient for endotracheal intubation is impossible. Results from multiple high-level studies in anesthetized patients that compared the LMA with endotracheal intubation (LOE 2)39,42– 46 and multiple additional studies that compared the LMA with other airways or ventilation techniques (LOE 2)2,47–52 support the use of the LMA in controlling the airway in a variety of settings by nurses, respiratory therapists, and EMS personnel, many of whom had not previously used this device. After successful insertion a small proportion of patients cannot be ventilated with the LMA.2,25,33 With this in mind, it is important for providers to have an alternative strategy for management of the airway. Providers who insert the LMA should receive adequate initial training and should practice insertion of the device regularly. Success rates and the occurrence of complications should be monitored closely. It is acceptable for healthcare professionals to use the LMA as an alternative to the endotracheal tube for airway manage￾ment in cardiac arrest (Class IIa). Endotracheal Intubation The endotracheal tube keeps the airway patent, permits suctioning of airway secretions, enables delivery of a high concentration of oxygen, provides an alternative route for the administration of some drugs, facilitates delivery of a selected tidal volume, and with use of a cuff may protect the airway from aspiration.53 Endotracheal intubation attempts by unskilled providers can produce complications, such as trauma to the oropharynx, interruption of compressions and ventilations for unaccept￾ably long periods, and hypoxemia from prolonged intubation attempts or failure to recognize tube misplacement or dis￾placement. Providers who perform endotracheal intubation require adequate initial training and either frequent experi￾ence or frequent retraining (Class I). EMS systems that provide prehospital intubation should establish a process for ongoing quality improvement to minimize complications (Class IIa). Indications for emergency endotracheal intubation are (1) the inability of the rescuer to adequately ventilate the uncon￾scious patient with a bag and mask and (2) the absence of airway protective reflexes (coma or cardiac arrest). The rescuer must have appropriate training and experience in endotracheal intubation. During CPR we recommend that rescuers minimize the number and duration of interruptions in chest compressions, with a goal to limit interruptions to no more than 10 seconds except as needed for interventions such as placement of an advanced airway. Interruptions needed for intubation can be minimized if the intubating rescuer is prepared to begin the intubation attempt (ie, insert the laryngoscope blade with the tube ready at hand) as soon as the compressing rescuer pauses compressions. The compressions should be interrupted only as long as the intubating rescuer needs to visualize the vocal cords and insert the tube. The compressing rescuer should be prepared to resume chest compressions immediately after the tube is passed through the vocal cords. If more than one intubation attempt is required, the rescuers should provide a period of adequate ventilation and oxygenation and chest compressions between attempts. If endotracheal intubation is performed for the patient with a perfusing rhythm, use pulse oximetry and ECG monitoring continuously during intubation attempts and interrupt the attempt to provide oxygenation and ventilation if needed. Even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventila￾tion, rescuers should obtain additional confirmation of place￾ment using an end-tidal CO2 or esophageal detection device (Class IIa).54 There is a high risk of tube misplacement, displacement, or obstruction,16,20 especially when the patient is moved.55 No single confirmation technique, including clinical signs56 or the presence of water vapor in the tube,57 is completely reliable. Techniques to confirm endotracheal tube Part 7.1: Adjuncts for Airway Control and Ventilation IV-53