Question: This question is regarding advance airway. I really don't like the basic airway first then if there is a problem, now go to the advance airway, ie: intubation, I have had saves due intubation right away. Once the vomit starts it's very hard to control the airway or intubate, during CPR, the vomit can come out in excess amounts that the suction cannot keep up with, let alone if by chance you do get a save, the patient dies of aspiration pneumonia later! Yes it's a paramedic's discretion to intubate or not, if you have a good seal with a basic airway and an IV you can run a code, and it's also said intubation stops CPR, well all the CPR in the world won't help if the airway is uncontrolled. This ROC survey with basic airway for the first 6 minutes can really cause a negative patient outcome if he vomits in excess. Well at least my compression stats are good!!!! Maybe this should be discussed in the next recert. Signed an ALS Paramedic.

 Thanks for the contribution. We are not really sure if you have a specific question in mind but rather disagree with the timing of the placement of advanced airways. The good news is that you have discovered one of the most active debates in the literature of pre-hospital medicine.

The rationale for the de-emphasis of early intubation is complex. There certainly are some advantages of early ETT placement as you describe and the exact timing of the placement of the advanced airway remains a hotly contested topic. A great summary and discussion on this topic can be found in the 2010 AHA Guidelines for Adult Advanced Cardiovascular Life Support (Neumar et al, Circulation 2010).

A link to these guidelines is here: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full

These guidelines state: "Advantages of advanced airway placement include elimination of the need for pauses in chest compressions for ventilation, potentially improved ventilation and oxygenation, reduction in the risk of aspiration, and ability to use quantitative waveform capnography to monitor quality of CPR, optimize chest compressions, and detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. The primary disadvantages are interruptions in chest compression during placement and the risk of unrecognized esophageal intubation.

There is inadequate evidence to define the optimal timing of advanced airway placement in relation to other interventions during resuscitation from cardiac arrest. There are no prospective studies that directly address the relationship between timing or type of advanced airway placement during CPR and outcomes. In an urban out-of-hospital setting, intubation in < 12 minutes has been associated with a better rate of survival than intubation in ‰¥13 minutes.(1) In a registry study of 25 006 in-hospital cardiac arrests, earlier time to advanced airway (< 5 minutes) was not associated with increased ROSC but was associated with improved 24-hour survival.(2) In out-of-hospital urban and rural settings, patients intubated during resuscitation had better survival rates than patients who were not intubated.(3) In an in-hospital setting patients requiring intubation during CPR had worse survival rates.(4) A recent study (5) 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/VT."

1. Shy BD, Rea TD, Becker LJ, Eisenberg MS. Time to intubation and survival in prehospital cardiac arrest. Prehosp Emerg Care. 2004;8:394€“399.
2. Wong ML, Carey S, Mader TJ, Wang HE. Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest. Resuscitation. 2010;81:182€“186.
3. Jennings PA, Cameron P, Walker T, Bernard S, Smith K. Out-of-hospital cardiac arrest in Victoria: rural and urban outcomes. Med J Aust. 2006;185:135€“139.
4. Dumot JA, Burval DJ, Sprung J, Waters JH, Mraovic B, Karafa MT, Mascha EJ, Bourke DL. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. Arch Intern Med. 2001;161:1751€“1758.
5. Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656€“662.

A recent article published in the Journal of the American Medical Association (Hasegawa et al JAMA. 2013;309(3):257-266) found that among nearly 650 000 adult patients who suffered out of hospital cardiac arrest, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

In the end, this debate will continue as to the role and timing of advanced airways for patients who have suffered out of hospital cardiac arrest.

Airway/Breathing,Cardiac/Circulation,Medical Cardiac Arrest,Orotracheal Intubation

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