Intra-Arrest: Airway and Ventilation Management

Oxygen Dose During CPR

Last Full Review: ILCOR 2020 (Children and Infants); ILCOR 2015 (Adults)
Last Update: 2021

The use of oxygen during cardiopulmonary resuscitation (CPR) is recommended to help correct tissue hypoxia. Post-return of spontaneous circulation (ROSC) oxygen therapy is guided by oximetry and capnography, with the goal of preventing hypoxia while preventing hyperoxia. Is there a specific concentration of oxygen recommended during CPR?

 

Evidence Summary

A 2021 American Red Cross Scientific Advisory Council literature update did not identify human studies addressing this topic since 2015, and guidelines remain unchanged. A systematic review (Callaway et al. 2015, S84) was last completed by International Liaison Committee on Resuscitation (ILCOR) in 2015, evaluating evidence comparing the administration of a maximal oxygen concentration to adults in cardiac arrest in any setting with no supplementary oxygen or a reduced oxygen concentration. No direct comparative evidence was identified in the review, however, a single retrospective observational study (Spindelboeck et al. 2013, 770) was described, enrolling 145 patients with an advanced airway who, during CPR, received 100% inspired oxygen and had a partial pressure of oxygen (PaO₂) value measured. The study reported improved ROSC with higher (PaO₂) measurements during CPR, while for the outcomes of survival to hospital discharge with favorable neurologic outcome, no difference was found between an intermediate (PaO₂) and a low (PaO₂) value during CPR. A weak recommendation was made by ILCOR suggesting the use of the highest possible inspired oxygen concentration during CPR (Callaway et al. 2015, S84). A 2020 ILCOR scoping review (Ong et al. 2021) of oxygen dosing during the provision of CPR in children and infants did not identify human studies (beyond the neonatal period). A previous treatment recommendation was restated that there is insufficient information to recommend for or against any specific inspired oxygen concentration during and immediately after resuscitation from cardiac arrest, and until additional evidence is published, they support healthcare providers’ use of 100% oxygen during resuscitation, when available.

Insights and Implications

The degree of tissue hypoxemia following cardiac arrest will vary depending on the etiology of the arrest and the time between onset of arrest and commencing CPR and advanced life support. For cardiac arrest precipitated by respiratory events, drowning or asphyxia, the use of maximal concentrations of oxygen during CPR is likely more important than for cardiac arrest of primary cardiac etiology and with immediate bystander response, but this remains a knowledge gap. The limited evidence available supports the administration of the highest concentration oxygen possible during CPR of adults and children.

Front of Neck Airway Access in Adult Cardiac Arrest

Last Full Review: ILCOR 2024

Front of neck airway access refers to emergency cricothyroidotomy and tracheostomy. These procedures are performed to secure an airway when conventional approaches, such as endotracheal intubation, have failed or are not feasible. Emergency cricothyroidotomy and tracheostomy are uncommon for patients with severe facial trauma in the prehospital and emergency department setting. 

Outside of trauma, a patient may develop a foreign body airway obstruction that cannot be resolved with standard approaches, or they may have pre-existing anatomical structural airway abnormalities creating a difficult airway before a cardiac arrest even occurs. In other cases, medical conditions, such as angioedema, can lead to airway obstruction and cardiac arrest.

No matter the reason, when there is inability to secure an airway and ventilate, emergency front of neck access is indicated. Front of neck airway access during cardiac arrest has not previously been reviewed by the International Liaison Committee on Resuscitation (ILCOR) or the American Red Cross Scientific Advisory Council.

 

Evidence Summary

A 2024 scoping review (Aljanoubi et al. 2023; Aljanoubi et al. 2024, 100653; Greif et al. 2024) by ILCOR sought evidence for attempting front of neck airway access, compared with ongoing attempts at basic or advanced airway management strategies, in adults in cardiac arrest in any setting in which adequate ventilation cannot be rapidly achieved by using basic or advanced airway management strategies. The review included one randomized controlled trial (RCT) and 68 observational studies with 4457 emergency front of neck access attempts in prehospital, in-hospital and military settings. None of the studies focused on cardiac arrest. The RCT assessed the success rate of percutaneous cricothyrotomy compared with percutaneous dilational tracheostomy. Observational studies included were mostly from a trauma setting or a mix of trauma and medical emergencies. Cricothyrotomy was used in most studies for emergency airway access. The reported success rate for front of neck airway access was greater than 70% for most studies. Rates of return of spontaneous circulation in cardiac arrest patients ranged from 0% to 64%. Reporting of complications was inconsistent (Aljanoubi et al. 2023; Aljanoubi et al. 2024, 100653; Greif et al. 2024). The review authors emphasized that no studies specifically examined patients in cardiac arrest.  As such, the incidence of front of neck airway access attempts in this population is uncertain, but the success rate for attempted access was generally high. A new good practice statement was made by ILCOR:

• In adults in cardiac arrest, when standard airway management strategies (e.g., oropharyngeal airway and bag-mask, supraglottic airway, or tracheal tube) have failed, it is reasonable for appropriately trained rescuers to attempt front of neck airway access using a cricothyroidotomy technique.

 

 

Insights and Implications

The Red Cross guideline is informed by this ILCOR scoping review and good practice statement. The statement has significant implications for resources and training. While the success rate for emergency front of neck airway access attempts in the included studies was generally high, this may reflect the healthcare professional’s specialty training (predominantly emergency medicine physicians), specific procedure training, prior experience with emergency front of neck airway access and/or the use of manufactured cricothyrotomy kits designed to facilitate rapid airway access. 

Commercial prepackaged sterile cricothyrotomy kits are stocked in many emergency departments and ambulances and contain all necessary components for performing a cricothyrotomy. Some simplify the procedure by integrating the introducer needle and airway tube. Healthcare professionals with prior training and experience with emergency front of neck airway access may prefer specific approaches and devices.