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Management of Ventilation
During Resuscitation
Marsh Cuttino, MD
CONTENTS
INTRODUCTION
VENTILATION
INDICATIONS FOR ASSISTED VENTILATION
TECHNIQUE
VENTILATION VOLUME
INTERMEDIATE AIRWAY TECHNIQUES AND DEVICES
ADVANCED AIRWAYS
CONCLUSION
REFERENCES
INTRODUCTION
The decision to control a patients airway during cardiopulmonary resuscitation (CPR)
is straightforward. Patients in cardiopulmonary arrest generally are totally unresponsive,
and airway techniques can be used without the need for pharmacological adjuncts. Much
of the decision making relates to timing and the type of ventilation method to use. These
decisions are influenced by the patients oxygenation status, duration of arrest, expected
difficulties with airway control, and operator experience and training.
VENTILATION
Establishing a secure patent airway is one of the primary tasks of the emergency care
provider during resuscitation. Adequate ventilation can reduce hypoxia and hypercapnea.
The airway should be obtained as soon as possible during resuscitation. Failure to control
the airway can have ominous consequences.
Endotracheal intubation is considered the optimal method for securing the airway
currently because it allows adequate ventilation, oxygenation, and airway protection.
The Combitube (Kendall Healthcare Products, Mansfield, MA) and laryngeal mask airway (LMA North America, San Diego, CA) are acceptable and possibly helpful alternative airway devices.
The main advantages of alternative airway devices is that they (a) are generally easier
to insert than an endotracheal tube (ETT); (b) may provide ventilation results similar to
From: Contemporary Cardiology: Cardiopulmonary Resuscitation
Edited by: J. P. Ornato and M. A. Peberdy Humana Press Inc., Totowa, NJ
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Cardiopulmonary Resuscitation
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nose and mouth. If the airway and breathing are inadequate, the airway should be opened.
In the unresponsive patient, the tongue and epiglottis may be obstructing the pharynx.
There are two techniques for opening an airway manually: the head tiltchin lift and
the jaw thrust maneuver. In some patients, spontaneous breathing returns after the airway
becomes patent. These patients should then be placed in a recovery position to reduce the
risk of aspiration. The American Heart Association (AHA) Guidelines released in 2000
for the recovery position include the following (11):
Use a lateral position, with the head dependent to allow free fluid drainage.
Make sure position is stable.
Avoid pressure on the chest that impairs breathing.
Good observation and access to the airway should be possible.
The position should not give rise to injury to the patient.
It should be possible to return the patient to the supine position quickly and easily, and
maintain cervical stability.
Repositioning should occur to prevent prolonged time in one position.
Patient should be monitored until airway is definitively secured.
Jaw Thrust
Grasping the angles of the jaw with the index and middle fingers and lifting with both
hands performs the jaw thrust. The head is maintained in the neutral position without any
flexion or extension. As the jaw is lifted, the patients mouth is opened with the thumbs.
This is the preferred method when there is a possibility of cervical spine injury.
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compression alone is still better than no CPR (13). All out of hospital pediatric arrest
victims should receive mouth-to-mouth ventilation, since most pediatric CA have a large
respiratory component (14).
TECHNIQUE
Mouth-to-mouth ventilation is the most basic form of positive pressure ventilation.
The rescuer positions him or herself at the patients side. After opening the airway, the
rescuer takes a deep breath, pinches the patients nose, and seals his or her mouth around
the patients mouth. Slow deep breaths are delivered, and after each breath the mouth is
removed to allow passive exhalation. Using slow breaths helps prevent gastric inflation
and aspiration from reflux and regurgitation.
Mouth-to-Shield Ventilation
Face shields are small, disposable, plastic barrier devices that can be used during
mouth-to-mouth ventilation. This removes any concern over infectious disease transmission. Shields may have enhancements such as one-way valves. The rescuer positions the
shield on the patient, pinches the nose and seals his or her mouth around the center
opening of the face shield. After the appropriate breaths are delivered, the rescuer lifts his
or her mouth from the shield and allows the patient to exhale. Figure 1 shows an example
of a pocket shield device. There are numerous other examples available on the market
with similar function.
Mouth-to-Mask Method
Another technique designed to isolate the rescuer from the patient is the mouth-tomask method. A standard face mask is used and fitted over the mouth using the same
position as used for the bag-valve-mask (Fig. 2). The rescuer can provide rescue breaths
either into the mask directly or indirectly using a one-way valve adapter. When the
adapter is used the face mask must be released to allow exhalation.
VENTILATION VOLUME
Mouth-to-mouth ventilation with a tidal volume of 1000 mL contains about 17%
oxygen and about 4% carbon dioxide (15). The gas composition can be improved to about
19% oxygen and 23% carbon dioxide by taking a deep breath and exhaling only about
500 mL (16). With normal cardiac output, tidal volumes of 8001000 mL are required
to maintain adequate oxygenation (17,18). Some authors have suggested that because
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cardiac output is reduced to at best 2030% of normal during CPR there is a reduced
requirement for ventilation (19,20). It appears that a tidal volume of 500 mL may be
adequate during CPR when supplemental oxygen is added (21). Current guidelines recommend a tidal volume of 10 mL/kg or 700 to 1000 mL over 2 seconds (13).
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Cardiopulmonary Resuscitation
Techniques
SINGLE OPERATOR
The rescuer stands at the head of the patient. The mask is applied to the patients face
with one hand. The thumb and index fingers secure the mask, and the remaining fingers
are placed over the bony portion of the mandible. As the rescuer ventilates the patient,
the fingers on the mandible maintain the head tilt and jaw thrust to keep the airway patent
and the mask snug against the face.
DUAL OPERATORS
The first rescuer stands at the head of the patient. The mask is applied to the patients
face, and the thumb and index fingers of both hands secure the mask and maintain a good
seal. The remaining fingers are used on the bony portion of the mandible to maintain the
head tilt and jaw thrust. The second rescuer stands to the right of the patient, and provides
two-handed compression of the bag to ventilate the patient (Fig. 4).
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Fig. 4. Two-person bag-valve-mask technique. Note the set of hands on the bottom left maintaining in-line cervical stabilization.
The distal portion of the airway should remain outside of the mouth to ensure that it does
not become an airway obstruction.
If the patient begins to gag, the oropharyngeal airway should be pulled out. The
oropharyngeal airway may be contraindicated in facial or mandibular trauma patients.
This airway will not maintain a patent airway if the patient has incorrect head placement.
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ADVANCED AIRWAYS
Orotracheal Intubation
The most common technique of advanced airway control is orotracheal intubation
with direct visualization laryngoscopy. Laryngoscopes are used to provide a direct view
of the vocal cords and facilitate placement of the ETT. Most intubations during CPR
are crash airways and do not require pharmacologic adjuncts such as rapid sequence
induction.
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difference in the usage of the blades regards the epiglottis. A straight blade lifts the
epiglottis directly, but the curved blade tip fits in the vallecula and indirectly lifts the
epiglottis.
The choice of which blade to use should be based on the patients clinical history.
Straight blades are better for pediatric patients, patients with an anterior larynx,
patients with a long floppy epiglottis, or patients with a scarred epiglottis. Straight
blades allow for more control of the airway in trauma patients, and may offer some
advantages when there is debris in the airway. There are several disadvantages with
straight blades. They are hard to use with large teeth, and may be more likely to break
teeth than their curved counterparts. Straight blades can stimulate the superior laryngeal nerve and lead to laryngospasm. These blades can be inserted inadvertently into
the esophagus and lead to esophageal intubation. Curved blades offer better control of
the tongue can allow more room in the hypopharynx to pass the endotracheal tube.
Curved blades possibly require less forearm strength to use. Medical providers with
less experience frequently prefer curved blades as they can provide a superior view
with less provider effort.
Endotracheal Tubes
The standard endotracheal tube is plastic and about 30 cm in length (Fig. 9). The tube
size is measured based on the internal diameter in millimeters. An adult male usually
requires a 7.59.0 mm ETT, however women can usually be intubated with a 7.08.0 mm
tube. The best time to intubate a patient during resuscitation is often described as as soon
as physically possible. Animal models of out-of-hospital arrest suggest that the defini-
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tive airway can be delayed for 56 minutes without decreasing the likelihood of spontaneous return of circulation (5).
Technique
PREPARE EQUIPMENT
1. Check suctioning equipment.
2. Inflate and deflate the endotracheal tube balloon to check for leaks.
3. Connect laryngoscope blade to the handle to check bulb function.
POSITION
1. Place the patients head in the sniffing position if no evidence of trauma.
2. If trauma is suspected, maintain in-line cervical stabilization in the neutral position.
3. Preoxygenate.
4. Maximize oxygen saturation by administering 100% O2 preferably by face mask or bagvalve-mask.
5. Pass the tube.
6. Holding the laryngoscope in the left hand, insert the laryngoscope into the right side
of the mouth and sweep the tongue to the left. Advance the blade and visualize the
epiglottis and vocal cords. Insert the endotracheal tube through the vocal cords. Inflate
the balloon.
PLACEMENT
Check for tube placement by auscultating over the chest and abdomen. If capnometry
or capnography is available, it can be used to confirm placement. Capnometry (colorimetric, analog, or digital) can yield false negative results during low-flow states such as
during resuscitation. Capnography remains accurate in determining endotracheal tube
placement even in the presence of a low-flow state. An alternate method to confirm ETT
placement is to use an esophageal detector suction device. When time allows, obtain a
chest x-ray to confirm endotracheal tube location.
DEVICES FOR CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT
There are numerous devices that can be utilized to confirm the proper placement of an
ETT. A detailed examination of placement confirmation devices is beyond the scope of
this chapter.
Capnography uses a chemical paper to rapidly determine the presence of carbon dioxide in exhaled air. This is a qualitative, not quantitative device. A change in color suggests
tracheal intubation (Fig. 10).
To use the bulb suction device, first deflate the bulb with the thumb and then place the
device securely on the ETT connector (Fig. 11). The bulb is released, and if the endotracheal tube is inserted in the esophagus the suction of the bulb collapses the flexible
tissue of the esophagus and the bulb does not inflate. With proper placement the rigid
structures of the trachea do not collapse and the bulb rapidly inflates. Rapid bulb inflation
confirms tracheal intubation.
A similar technique is used with the syringe aspiration test (Fig. 12). Instead of bulb
inflation, the syringe is attached and the plunger rapidly drawn back by the provider.
Increased resistance suggests esophageal intubation.
These confirmation techniques have the advantage that they can be utilized in high
noise environments or in situations in which stethoscopes are unavailable or unusable,
such as during a disaster.
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Combitube
The Combitube is a double lumen tube with two balloons (Fig. 13). It is designed for
blind insertion during emergency situations and difficult airways. The esophageal obturator tube is sealed at the distal end, and has perforations at the pharyngeal level. The
tracheal tube has a clear distal opening. The large upper oropharyngeal balloon serves to
seal off the mouth and nose. The distal cuff balloon seals off either the trachea or the
esophagus.
One advantage of the Combitube is that insertion requires less skill than direct laryngoscopy. Because it can be inserted blindly, it can be used under difficult lighting and
space restrictions. It is very useful when visualization of the vocal cords is impossible.
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Cardiopulmonary Resuscitation
Contraindications include patients with intact gag reflexes, patient height less than 4 feet,
a history of known esophageal pathology, a recent history of ingestion of caustic substances, or central airway obstruction.
TECHNIQUE
To insert a Combitube, grasp the back of the tongue and jaw between the thumb and
index finger and lift. Insert the Combitube in a curved downward motion. Insertion
should not require any force by the operator. Inflate the oropharyngeal balloon first with
between 85 and 100 cc of air (depending on the size of the Combitube) then inflate the
distal balloon with 515 cc of air.
The most likely result of a blind intubation is esophageal intubation. Attempt ventilation through the longer blue tube. If breath sounds are present then the tip of the
Combitube is in the esophagus. If breath sounds are absent, then the tip of the tube is in
the trachea. If the tube has entered the trachea, ventilation is performed using the distal
lumen just like a standard endotracheal tube. Tracheal intubation can be achieved by
using a laryngoscope in conjunction with a Combitube.
CONCLUSION
Providers should be familiar with BLS techniques in addition to advanced airway techniques. The patients airway should be secured definitively within the first 56 minutes of
CPR. This allows for adequate ventilation, and increases the possibility of return of spontaneous circulation. Endotracheal intubation is the method most commonly used to secure
the airway. Alternative methods include the Combitube and LMA. The position of an
advanced airway should be confirmed with capnography or an esophageal detector device.
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