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Should We Pause Compressions to Intubate During CPR?

March 23, 2023

Written by Steven Mowen

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Routinely pausing chest compressions during cardiac arrest to intubate in the emergency department is not necessary; this is especially true if you have video laryngoscopy and a bougie.

Why does this matter?
There are obvious but poorly studied benefits to having a secured airway during active resuscitation of cardiac arrest patient in the ED. Endotracheal intubation, once a patient arrives to the hospital in cardiac arrest, is still commonly performed, and properly securing a patient’s airway in cardiac arrest should not necessitate an interruption of chest compressions.

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This was a retrospective, observational study from a large academic center and included 169 patients for analysis over a 5-year period. 143 intubations were attempted during continuous compressions with an 87% first-attempt success rate. This was higher than the first attempt success for interrupted compressions group at 65%. 

Although method of compressions, mechanical vs. manual differed, there was no statistical significance between the two groups in adjusted analysis. Most intubations were performed by senior residents (≥PGY 3) and attendings (>85%), with more than 90% of the intubations performed with video laryngoscope/bougie.

Most patients, for either group, were intubated within 6 minutes of arrival to the ED. Average first attempt success time was 48 seconds in continued vs. 43 seconds in paused compressions. If the airway was missed the first-time during CPR, compressions were continued during the second (and successful) attempt 15/18 times.

There is no definitive optimal airway approach during an arrest. Logistical factors in the out-of-hospital setting make a supraglottic approach with focus on good cardiac resuscitation an ideal model for resuscitation. Once a patient arrives to the hospital, however, a definitive endotracheal airway is still commonplace. However, securing this airway should not compromise CPR, and this study supports intubating without stopping compressions.

Peer Reviewed by Dr. Ketan Patel

First Attempt Success with Continued versus Paused Chest Compressions During Cardiac Arrest in the Emergency Department. Resuscitation. 2023 Feb 8;109726. doi: 10.1016/j.resuscitation.2023.109726. Online ahead of print.

Editor’s Note: There is concern for confounding in this retrospective, video review study, which the authors acknowledged. It is likely that patients with pauses in compressions were also those with a more difficult airway. ~Clay Smith