Airway management in cardiopulmonary resuscitation

The optimal method for airway management during cardiac arrest is unknown. This review summarizes recent evidence comparing the use of basic and advanced airway interventions [insertion of supraglottic airway (SGA) devices and tracheal intubation], including the role of capnography during cardiac arrest.

A large observational study [649,359 out-of-hospital cardiac arrests (OHCAs)] has shown that the risk-adjusted odds of neurologically favourable survival were higher for those treated with bag-mask ventilation compared with SGA insertion or tracheal intubation. Two recent, large observational studies suggest that tracheal intubation for OHCA may be superior to SGA use. These observational studies share an important weakness: they rely on statistical risk-adjustment to account for other factors that may influence outcome, and hidden confounders may account for the differences in outcome associated with each of the airway management strategies.

Most of the evidence about airway management during cardiac arrest comes from observational studies. The best airway option is likely to be different for different rescuers, and at different time points of the resuscitation process. Properly designed, prospective, randomized trials are needed to help determine the optimal airway strategy. In our view, there is currently sufficient clinical equipoise to support such trials.