Chapter 5 / Management of Ventilation



Management of Ventilation
During Resuscitation
Marsh Cuttino, MD

The decision to control a patient’s 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 patient’s oxygenation status, duration of arrest, expected
difficulties with airway control, and operator experience and training.

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


peak airway pressure. Successful ventilation with rapid and uninterrupted chest compressions significantly improves coronary perfusion during CPR (6) and this makes successful defibrillation more likely (7). Accidental stomach inflation during CPR can elevate intragastric pressure and lead to the cascade of regurgitation. This allows the operator to be flexible in the management of the airway as the situation demands. listening for exhaled breath. pulse oximetry. then an alternative airway should be employed. Bystander CPR for the first 5 minutes has equivalent outcomes with or without mouth-to-mouth ventilation (9). Objective indicators of ventilatory status include arterial blood gas. Some patients are intubated for airway protection and others are intubated specifically for failure of ventilation or oxygenation. the cervical spine must be protected. Methods to maintain an open airway range from BLS measures (e. Adequate ventilation is important for return of spontaneous circulation (5). and feeling for air exchange at the . Medical providers should be proficient in several techniques at each level of airway control. chest radiography. 100% oxygen should be started immediately using a bag-valve-mask. and spirometry. aspiration. and death even in the successfully resuscitated patient (3). capnography. and the patient should be log rolled. need for neuromuscular blockade.. and the emergency response system has been activated.g.g. pneumonia.. and the technique of the rescuer performing basic life support (BLS. alternative airway devices can sometimes be used when tracheal intubation is not possible (1). respiratory mechanics (the respiratory system compliance and degree of airway obstruction). safety of the technique. inspiratory flow rate. Although the minute ventilation requirements may be decreased by a low cardiac output. Ventilation has an impact on blood gases even at very low cardiac output states (4). cervical spine stability. airway patency. Important considerations include adequacy of ventilation. INDICATIONS FOR ASSISTED VENTILATION Rapid assessment of the patient allows for appropriate decision on airway management. Additionally. This suggests that airway control is most useful when achieved in the first 5–6 minutes of CA. the airway needs to be assessed. This should be followed rapidly by endotracheal intubation once skilled individuals arrive on scene. and can be corrected with appropriate ventilation. and tidal volume). head tilt–chin lift) to advanced airway techniques (e. When a nonintubated patient is ventilated.96 Cardiopulmonary Resuscitation that provided by endotracheal intubation and superior to bag-valve-mask ventilation. the excess load of carbon dioxide returning from ischemic tissue beds must be cleared by ventilation. the patient should be placed in the supine position. Chest compressions alone do not generate adequate or consistent ventilation in humans. Once a patient has been found to be unresponsive. the distribution of gas between the lungs and stomach depends on the patient’s lower esophageal sphincter pressure. In the resuscitation patient. endotracheal intubation). If trauma is suspected. Hypoxia and hypercarbia have an independent adverse effect on resuscitation. If intubation is unsuccessful. even after intubation (2). and the skill of the operator (10). and (c) have similar complication rates to endotracheal intubation. The rescuer should open the airway and assess breathing by looking for a chest rise. In cardiac arrest (CA) there is generally sufficient oxygenation in the blood that a reasonable oxygen saturation persists for approx 5 minutes when there is adequate chest compression (8). First. The amount of ventilation required during resuscitation is not well established.

but recognize that basic CPR with chest . rescue breathing must be performed. • Make sure position is stable.Chapter 5 / Management of Ventilation 97 nose and mouth. normal breathing. Head Tilt–Chin Lift Placing one hand on the patient’s forehead and the index and middle finger of the other hand on the bony part of the chin performs the head tilt–chin lift. Current guidelines still recommend mouthto-mouth ventilation in out-of-hospital arrest. In some patients.g. or normal movement in response to stimulation) rather than perform a pulse check to determine if chest compression’s should be administered. This has led to consideration of removing mouth-tomouth ventilation guidelines from CPR (9). • It should be possible to return the patient to the supine position quickly and easily. then look. the patient’s mouth is opened with the thumbs. and maintain cervical stability. spontaneous breathing returns after the airway becomes patent. If the patient is not breathing adequately. Mouth-to-Mouth Ventilation and Variants Rescue breathing through mouth-to-mouth ventilation has been an important part of CPR for more than 30 years. Rescue breathing for both single rescuer CPR and multiple rescuer CPR with an unprotected airway is at a 15:2 ratio of chest compression to breathing with a rate of 100 compressions per minute (11). Trained health care providers are encouraged to check for a pulse. opening the airway. The head is maintained in the neutral position without any flexion or extension. There are two techniques for opening an airway manually: the head tilt–chin lift and the jaw thrust maneuver. coughing. In the unresponsive patient. the airway should be opened. Jaw Thrust Grasping the angles of the jaw with the index and middle fingers and lifting with both hands performs the jaw thrust. As the jaw is lifted. 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. • Repositioning should occur to prevent prolonged time in one position. Concern about transmission of infectious disease has made both professional medical providers and lay people reluctant to provide mouth-to-mouth ventilation to adult strangers (12). The AHA recommends that lay rescuers check for “signs of circulation” (e.. and feel for breathing. • The position should not give rise to injury to the patient. Basic Life Support Techniques The first step is to open the airway. These patients should then be placed in a recovery position to reduce the risk of aspiration. This is the preferred method when there is a possibility of cervical spine injury. • Patient should be monitored until airway is definitively secured. • Good observation and access to the airway should be possible. If the airway and breathing are inadequate. • Avoid pressure on the chest that impairs breathing. listen. This lifts the jaw and elevates the tongue off the back of the pharynx. the tongue and epiglottis may be obstructing the pharynx. The patient’s head is rotated as the chin is lifted.

or severe trauma could prevent formation of an appropriate seal. The appropriate breaths are delivered. and the mouth is removed from the patient’s nose to allow passive exhalation. It may be necessary to open the mouth intermittently to allow complete exhalation. Slow deep breaths are delivered. and after each breath the mouth is removed to allow passive exhalation. After opening the airway.98 Cardiopulmonary Resuscitation compression alone is still better than no CPR (13). VENTILATION VOLUME Mouth-to-mouth ventilation with a tidal volume of 1000 mL contains about 17% oxygen and about 4% carbon dioxide (15). trismus. When the adapter is used the face mask must be released to allow exhalation. A standard face mask is used and fitted over the mouth using the same position as used for the bag-valve-mask (Fig. Mouth-to-Nose Rescue Breathing Mouth-to-nose rescue breathing can be used when there are contraindications to mouthto-mouth breathing. the rescuer lifts his or her mouth from the shield and allows the patient to exhale. One hand is placed on the forehead and the other lifts the mandible and closes the mouth. There are numerous other examples available on the market with similar function. disposable. and seals his or her mouth around the patient’s mouth. After the appropriate breaths are delivered. Shields may have enhancements such as one-way valves. Mouth-to-Mask Method Another technique designed to isolate the rescuer from the patient is the mouth-tomask method. pinches the patient’s nose. The gas composition can be improved to about 19% oxygen and 2–3% carbon dioxide by taking a deep breath and exhaling only about 500 mL (16). the rescuer takes a deep breath. Mouth-to-Shield Ventilation Face shields are small. tidal volumes of 800–1000 mL are required to maintain adequate oxygenation (17. This removes any concern over infectious disease transmission. Figure 1 shows an example of a pocket shield device. The rescuer positions him or herself at the patient’s side. The rescuer can provide rescue breaths either into the mask directly or indirectly using a one-way valve adapter. All out of hospital pediatric arrest victims should receive mouth-to-mouth ventilation. The rescuer positions the shield on the patient. With normal cardiac output. 2). Conditions such as anatomic abnormalities. The rescuer positions the patient’s head in extension. plastic barrier devices that can be used during mouth-to-mouth ventilation. TECHNIQUE Mouth-to-mouth ventilation is the most basic form of positive pressure ventilation. Using slow breaths helps prevent gastric inflation and aspiration from reflux and regurgitation. since most pediatric CA have a large respiratory component (14).18). pinches the nose and seals his or her mouth around the center opening of the face shield. The rescuer’s mouth is placed over the patient’s nose and a seal is formed with the lips. Some authors have suggested that because .

1. Example of a pocket shield device. 2. Current guidelines recommend a tidal volume of 10 mL/kg or 700 to 1000 mL over 2 seconds (13). . cardiac output is reduced to at best 20–30% of normal during CPR there is a reduced requirement for ventilation (19.20).Chapter 5 / Management of Ventilation 99 \ Fig. It appears that a tidal volume of 500 mL may be adequate during CPR when supplemental oxygen is added (21). Ventilation masks. Fig.

The key to proper use of the bag-valve-mask is to maintain a tight seal. Techniques SINGLE OPERATOR The rescuer stands at the head of the patient. INTERMEDIATE AIRWAY TECHNIQUES AND DEVICES Bag-Valve-Mask Device The bag-valve-mask is a common device for delivering positive pressure ventilation in the initial stages of resuscitation (Fig. The airway is inserted by turning it 90° and inserting it halfway into the mouth. choose one that fits from the middle of the mouth to the angle of the jaw.100 Cardiopulmonary Resuscitation Fig. This device should not be used on a patient who has an intact gag reflex. Example of a typical bag-valve-mask assembly. It is indicated in the unresponsive or obtunded patient and can be used in conjunction with a bag-valve-mask device. and provides two-handed compression of the bag to ventilate the patient (Fig. The thumb and index fingers secure the mask. 5). the fingers on the mandible maintain the head tilt and jaw thrust to keep the airway patent and the mask snug against the face. There are different techniques depending on whether there is a single operator or two operators. 3. . Oropharyngeal Airway Device An oropharyngeal airway is a plastic or rubber device that can be inserted into a victim’s mouth to elevate the tongue and create a path between the tongue and palate (Fig. The mask is applied to the patient’s face with one hand. 4). The remaining fingers are used on the bony portion of the mandible to maintain the head tilt and jaw thrust. and the thumb and index fingers of both hands secure the mask and maintain a good seal. DUAL OPERATORS The first rescuer stands at the head of the patient. 3). Then rotate back 90° so that the bottom wraps around the back of the tongue. As the rescuer ventilates the patient. and the remaining fingers are placed over the bony portion of the mandible. The mask is applied to the patient’s face. To size an oropharyngeal airway. The second rescuer stands to the right of the patient.

Chapter 5 / Management of Ventilation 101 Fig. Note the set of hands on the bottom left maintaining in-line cervical stabilization. If the patient begins to gag. Oropharyngeal airways. the oropharyngeal airway should be pulled out. The oropharyngeal airway may be contraindicated in facial or mandibular trauma patients. 5. . Fig. This airway will not maintain a patent airway if the patient has incorrect head placement. Two-person bag-valve-mask technique. The distal portion of the airway should remain outside of the mouth to ensure that it does not become an airway obstruction. 4.

6. Nasopharyngeal airways can be used with patients that still have an intact gag reflex. and the curve of the tube follows the curvature of the patient’s airway. choose a tube that extends from the tip of the nose to the angle of the patient’s mandible. Most intubations during CPR are “crash” airways and do not require pharmacologic adjuncts such as rapid sequence induction. Nasopharyngeal airways. A nasopharyngeal airway can help maintain airway patency in an unconscious or obtunded patient but does not ensure patency without good head positioning. 6). The diameter of the tube should approximate the diameter of the nares. Nasopharyngeal Airway Device A flexible tube designed to be inserted into the nares and extend to the base of the tongue (Fig. Laryngoscopes are used to provide a direct view of the vocal cords and facilitate placement of the ETT. ADVANCED AIRWAYS Orotracheal Intubation The most common technique of advanced airway control is orotracheal intubation with direct visualization laryngoscopy.102 Cardiopulmonary Resuscitation Fig. The tube is lubricated and inserted into the nares so that the beveled tip is midline. This airway adjunct can be used in conjunction with a bag-valve-mask to facilitate ventilation. . To size a nasopharyngeal airway.

There are two basic blade designs. The main . Various sizes are available for adult and pediatric use. typified by the MacIntosh blade.Chapter 5 / Management of Ventilation 103 Fig. 7. Examples of laryngoscope handles and blades. 7 and 8). The laryngoscope is an apparatus designed to permit direct visualization of the larynx and facilitate endotracheal intubation through direct laryngoscopy (Figs. The second type is the straight blade such as the Miller or Wisconsin blades (Welch Allyn. Skaneateles Falls. Fig. The first is the curved blade. Miller and MacIntosh laryngoscope blades. 8. NY).

or patients with a scarred epiglottis. Endotracheal Tubes The standard endotracheal tube is plastic and about 30 cm in length (Fig.0 mm tube. A straight blade lifts the epiglottis directly.104 Cardiopulmonary Resuscitation Fig. patients with an anterior larynx. The choice of which blade to use should be based on the patient’s clinical history. There are several disadvantages with straight blades. Straight blades can stimulate the superior laryngeal nerve and lead to laryngospasm. The best time to intubate a patient during resuscitation is often described as “as soon as physically possible. Straight blades allow for more control of the airway in trauma patients. An adult male usually requires a 7. but the curved blade tip fits in the vallecula and indirectly lifts the epiglottis. Endotracheal tubes. however women can usually be intubated with a 7. 9. difference in the usage of the blades regards the epiglottis. Curved blades offer better control of the tongue can allow more room in the hypopharynx to pass the endotracheal tube. The tube size is measured based on the internal diameter in millimeters. They are hard to use with large teeth. and may offer some advantages when there is debris in the airway.0 mm ETT.5–9. Medical providers with less experience frequently prefer curved blades as they can provide a superior view with less provider effort. Straight blades are better for pediatric patients. patients with a long floppy epiglottis. These blades can be inserted inadvertently into the esophagus and lead to esophageal intubation.0–8. and may be more likely to break teeth than their curved counterparts.” Animal models of out-of-hospital arrest suggest that the defini- . Curved blades possibly require less forearm strength to use. 9).

The bulb is released. This is a qualitative. not quantitative device. Rapid bulb inflation confirms tracheal intubation. Maximize oxygen saturation by administering 100% O2 preferably by face mask or bagvalve-mask. An alternate method to confirm ETT placement is to use an esophageal detector suction device. Capnography remains accurate in determining endotracheal tube placement even in the presence of a low-flow state. A change in color suggests tracheal intubation (Fig. insert the laryngoscope into the right side of the mouth and sweep the tongue to the left. Holding the laryngoscope in the left hand. 11). If trauma is suspected. DEVICES FOR CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT There are numerous devices that can be utilized to confirm the proper placement of an ETT. Check suctioning equipment. Capnometry (colorimetric. obtain a chest x-ray to confirm endotracheal tube location. If capnometry or capnography is available. 12). it can be used to confirm placement. . Increased resistance suggests esophageal intubation. Pass the tube. 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. analog. 6. Inflate and deflate the endotracheal tube balloon to check for leaks. Insert the endotracheal tube through the vocal cords. A detailed examination of placement confirmation devices is beyond the scope of this chapter. Instead of bulb inflation. When time allows. the syringe is attached and the plunger rapidly drawn back by the provider. Capnography uses a chemical paper to rapidly determine the presence of carbon dioxide in exhaled air. Place the patient’s head in the sniffing position if no evidence of trauma. Inflate the balloon. 4. such as during a disaster. maintain in-line cervical stabilization in the neutral position. 5.Chapter 5 / Management of Ventilation 105 tive airway can be delayed for 5–6 minutes without decreasing the likelihood of spontaneous return of circulation (5). Preoxygenate. 2. 3. Technique PREPARE EQUIPMENT 1. first deflate the bulb with the thumb and then place the device securely on the ETT connector (Fig. or digital) can yield false negative results during low-flow states such as during resuscitation. Connect laryngoscope blade to the handle to check bulb function. A similar technique is used with the syringe aspiration test (Fig. PLACEMENT Check for tube placement by auscultating over the chest and abdomen. 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. 10). Advance the blade and visualize the epiglottis and vocal cords. 3. 2. To use the bulb suction device. POSITION 1. With proper placement the rigid structures of the trachea do not collapse and the bulb rapidly inflates.

. Louis. 11.0 mm) than would be used for endotracheal intubation. Fig. Usually the tube size chosen is slightly smaller (by 0. As nasotracheal intubation requires that the patient be spontaneously breathing.5–1.. Example of a capnograph. Bulb esophageal detector. The Endotrol tube is an ETT with a loop attached that increases the curvature of the tip when pulled. The Endotrol is used during nasogastric intubation. 10. MO) is inserted through the nares down into the trachea. St. Endotrol Endotracheal Tube Nasotracheal intubation is an alternative technique in which the ETT or Endotrol tube (Mallinckrodt Critical Care Inc. it will not be considered further in this chapter.106 Cardiopulmonary Resuscitation Fig.

The esophageal obturator tube is sealed at the distal end. . The tracheal tube has a clear distal opening. Fig. 12. Combitube The Combitube is a double lumen tube with two balloons (Fig. One advantage of the Combitube is that insertion requires less skill than direct laryngoscopy. and has perforations at the pharyngeal level. Because it can be inserted blindly. It is very useful when visualization of the vocal cords is impossible. It is designed for blind insertion during emergency situations and difficult airways. 13). The distal cuff balloon seals off either the trachea or the esophagus. Syringe aspirator. 13. The large upper oropharyngeal balloon serves to seal off the mouth and nose.Chapter 5 / Management of Ventilation 107 Fig. Combitubes. it can be used under difficult lighting and space restrictions.

CONCLUSION Providers should be familiar with BLS techniques in addition to advanced airway techniques. Laryngeal Mask Airway The LMA was introduced into clinical practice in 1988. TECHNIQUE Completely deflate the LMA until the cuff forms a smooth spoon shape without any wrinkles. The position of an advanced airway should be confirmed with capnography or an esophageal detector device. then the tip of the tube is in the trachea. a recent history of ingestion of caustic substances. . and increases the possibility of return of spontaneous circulation. grasp the back of the tongue and jaw between the thumb and index finger and lift. Normal intracuff pressures are around 60 cm H2O. Attempt ventilation through the longer blue tube. Insert the Combitube in a curved downward motion. Tracheal intubation can be achieved by using a laryngoscope in conjunction with a Combitube. Advance the LMA into the hypopharynx until resistance is felt. Alternative methods include the Combitube and LMA. a history of known esophageal pathology. The most likely result of a blind intubation is esophageal intubation. The mask is deflated to form a flat wedge that will pass behind the tongue and behind the epiglottis. The mask is then inflated and seals off the laryngeal inlet. The LMA can be used when the patient is unresponsive or the protective reflexes have been sufficiently depressed. The patient’s airway should be secured definitively within the first 5–6 minutes of CPR. Hold the LMA like a pen. If breath sounds are present then the tip of the Combitube is in the esophagus.108 Cardiopulmonary Resuscitation Contraindications include patients with intact gag reflexes. The LMA is a triangular shaped inflatable pink silicon laryngeal mask (Fig. Endotracheal intubation is the method most commonly used to secure the airway. The mask has an opening in the middle that prevents accidental obstruction of the tube by the tip of the epiglottis. and provides almost no prevention of aspiration of stomach contents from below or blood and secretions from above. The LMA is best for providers not trained in endotracheal intubation. patient height less than 4 feet. ventilation is performed using the distal lumen just like a standard endotracheal tube. The LMA is not a definitive airway. If the tube has entered the trachea. The index finger can be used to assist in guiding the LMA behind the tongue. Inflate the cuff with enough air to obtain a seal. Gastric distention is minimized because excess pressure is vented upward around the LMA instead of into the esophagus. 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 5–15 cc of air. with the mask facing forward and the black line on the tube oriented toward the upper lip. Insert the mask with the tip of the cuff up toward the hard palate. 14). Insertion should not require any force by the operator. This allows for adequate ventilation. It can be used as an adjunct in the difficult airway when primary endotracheal intubation has been attempted unsuccessfully. TECHNIQUE To insert a Combitube. The LMA is blindly inserted into the pharynx with the point of the triangle in the esophagus and the mask over the laryngeal inlet. or central airway obstruction. If breath sounds are absent.

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