HomeCirculationVol. 122, No. 16_suppl_2Part 8: Advanced Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 8: Advanced Life Support2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Laurie J. Morrison, Charles D. Deakin, Peter T. Morley, Clifton W. Callaway, Richard E. Kerber, Steven L. Kronick, Eric J. Lavonas, Mark S. Link, Robert W. Neumar, Charles W. Otto, Michael Parr, Michael Shuster, Kjetil Sunde, Mary Ann Peberdy, Wanchun Tang, Terry L. Vanden Hoek, Bernd W. Böttiger, Saul Drajer, Swee Han Lim, Jerry P. Nolan, Advanced Life Support Chapter Collaborators Christophe Adrie, Mohammed Alhelail, Pavan Battu, Wilhelm Behringer, Lauren Berkow, Richard A. Bernstein, Sadiq S. Bhayani, Blair Bigham, Jeff Boyd, Barry Brenner, Eric Bruder, Hermann Brugger, Ian L. Cash, Maaret Castrén, Michael Cocchi, Gregory Comadira, Kate Crewdson, Michael S. Czekajlo, Suzanne R. Davies, Harinder Dhindsa, Deborah Diercks, C. Jessica Dine, Csaba Dioszeghy, Michael Donnino, Joel Dunning, Nabil El Sanadi, Heather Farley, Peter Fenici, V. Ramana Feeser, Jane A.H. Foster, Hans Friberg, Michael Fries, F. Javier Garcia-Vega, Romergryko G. Geocadin, Marios Georgiou, Jaspinder Ghuman, Melissa Givens, Colin Graham, David M. Greer, Henry R. Halperin, Amanda Hanson, Michael Holzer, Elizabeth A. Hunt, Masami Ishikawa, Marios Ioannides, Farida M. Jeejeebhoy, Paul A. Jennings, Hitoshi Kano, Karl B. Kern, Fulvio Kette, Peter J. Kudenchuk, Douglas Kupas, Giuseppe La Torre, Todd M. Larabee, Marion Leary, John Litell, Charles M. Little, David Lobel, Timothy J. Mader, James J. McCarthy, Michael C. McCrory, James J. Menegazzi, William J. Meurer, Paul M. Middleton, Allan R. Mottram, Eliano Pio Navarese, Thomas Nguyen, Marcus Ong, Andrew Padkin, Edison Ferreira de Paiva, Rod S. Passman, Tommaso Pellis, John J. Picard, Rachel Prout, Morten Pytte, Renee D. Reid, Jon Rittenberger, Will Ross, Sten Rubertsson, Malin Rundgren, Sebastian G. Russo, Tetsuya Sakamoto, Claudio Sandroni, Tommaso Sanna, Tomoyuki Sato, Sudhakar Sattur, Andrea Scapigliati, Richard Schilling, Ian Seppelt, Fred A. Severyn, Greene Shepherd, Richard D. Shih, Markus Skrifvars, Jasmeet Soar, Keiichi Tada, Sara Tararan, Michel Torbey, Jonathan Weinstock, Volker Wenzel, Christoph H. Wiese, Daniel Wu, Carolyn M. Zelop, David Zideman and Janice L. Zimmerman Laurie J. MorrisonLaurie J. Morrison *Co-chairs and equal first co-authors. Search for more papers by this author , Charles D. DeakinCharles D. Deakin *Co-chairs and equal first co-authors. Search for more papers by this author , Peter T. MorleyPeter T. Morley Search for more papers by this author , Clifton W. CallawayClifton W. Callaway Search for more papers by this author , Richard E. KerberRichard E. Kerber Search for more papers by this author , Steven L. KronickSteven L. Kronick Search for more papers by this author , Eric J. LavonasEric J. Lavonas Search for more papers by this author , Mark S. LinkMark S. Link Search for more papers by this author , Robert W. NeumarRobert W. Neumar Search for more papers by this author , Charles W. OttoCharles W. Otto Search for more papers by this author , Michael ParrMichael Parr Search for more papers by this author , Michael ShusterMichael Shuster Search for more papers by this author , Kjetil SundeKjetil Sunde Search for more papers by this author , Mary Ann PeberdyMary Ann Peberdy Search for more papers by this author , Wanchun TangWanchun Tang Search for more papers by this author , Terry L. Vanden HoekTerry L. Vanden Hoek Search for more papers by this author , Bernd W. BöttigerBernd W. Böttiger Search for more papers by this author , Saul DrajerSaul Drajer Search for more papers by this author , Swee Han LimSwee Han Lim Search for more papers by this author , Jerry P. NolanJerry P. Nolan Search for more papers by this author , Advanced Life Support Chapter Collaborators Search for more papers by this author , Christophe AdrieChristophe Adrie Search for more papers by this author , Mohammed AlhelailMohammed Alhelail Search for more papers by this author , Pavan BattuPavan Battu Search for more papers by this author , Wilhelm BehringerWilhelm Behringer Search for more papers by this author , Lauren BerkowLauren Berkow Search for more papers by this author , Richard A. BernsteinRichard A. Bernstein Search for more papers by this author , Sadiq S. BhayaniSadiq S. Bhayani Search for more papers by this author , Blair BighamBlair Bigham Search for more papers by this author , Jeff BoydJeff Boyd Search for more papers by this author , Barry BrennerBarry Brenner Search for more papers by this author , Eric BruderEric Bruder Search for more papers by this author , Hermann BruggerHermann Brugger Search for more papers by this author , Ian L. CashIan L. Cash Search for more papers by this author , Maaret CastrénMaaret Castrén Search for more papers by this author , Michael CocchiMichael Cocchi Search for more papers by this author , Gregory ComadiraGregory Comadira Search for more papers by this author , Kate CrewdsonKate Crewdson Search for more papers by this author , Michael S. CzekajloMichael S. Czekajlo Search for more papers by this author , Suzanne R. DaviesSuzanne R. Davies Search for more papers by this author , Harinder DhindsaHarinder Dhindsa Search for more papers by this author , Deborah DiercksDeborah Diercks Search for more papers by this author , C. Jessica DineC. Jessica Dine Search for more papers by this author , Csaba DioszeghyCsaba Dioszeghy Search for more papers by this author , Michael DonninoMichael Donnino Search for more papers by this author , Joel DunningJoel Dunning Search for more papers by this author , Nabil El SanadiNabil El Sanadi Search for more papers by this author , Heather FarleyHeather Farley Search for more papers by this author , Peter FeniciPeter Fenici Search for more papers by this author , V. Ramana FeeserV. Ramana Feeser Search for more papers by this author , Jane A.H. FosterJane A.H. Foster Search for more papers by this author , Hans FribergHans Friberg Search for more papers by this author , Michael FriesMichael Fries Search for more papers by this author , F. Javier Garcia-VegaF. Javier Garcia-Vega Search for more papers by this author , Romergryko G. GeocadinRomergryko G. Geocadin Search for more papers by this author , Marios GeorgiouMarios Georgiou Search for more papers by this author , Jaspinder GhumanJaspinder Ghuman Search for more papers by this author , Melissa GivensMelissa Givens Search for more papers by this author , Colin GrahamColin Graham Search for more papers by this author , David M. GreerDavid M. Greer Search for more papers by this author , Henry R. HalperinHenry R. Halperin Search for more papers by this author , Amanda HansonAmanda Hanson Search for more papers by this author , Michael HolzerMichael Holzer Search for more papers by this author , Elizabeth A. HuntElizabeth A. Hunt Search for more papers by this author , Masami IshikawaMasami Ishikawa Search for more papers by this author , Marios IoannidesMarios Ioannides Search for more papers by this author , Farida M. JeejeebhoyFarida M. Jeejeebhoy Search for more papers by this author , Paul A. JenningsPaul A. Jennings Search for more papers by this author , Hitoshi KanoHitoshi Kano Search for more papers by this author , Karl B. KernKarl B. Kern Search for more papers by this author , Fulvio KetteFulvio Kette Search for more papers by this author , Peter J. KudenchukPeter J. Kudenchuk Search for more papers by this author , Douglas KupasDouglas Kupas Search for more papers by this author , Giuseppe La TorreGiuseppe La Torre Search for more papers by this author , Todd M. LarabeeTodd M. Larabee Search for more papers by this author , Marion LearyMarion Leary Search for more papers by this author , John LitellJohn Litell Search for more papers by this author , Charles M. LittleCharles M. Little Search for more papers by this author , David LobelDavid Lobel Search for more papers by this author , Timothy J. MaderTimothy J. Mader Search for more papers by this author , James J. McCarthyJames J. McCarthy Search for more papers by this author , Michael C. McCroryMichael C. McCrory Search for more papers by this author , James J. MenegazziJames J. Menegazzi Search for more papers by this author , William J. MeurerWilliam J. Meurer Search for more papers by this author , Paul M. MiddletonPaul M. Middleton Search for more papers by this author , Allan R. MottramAllan R. Mottram Search for more papers by this author , Eliano Pio NavareseEliano Pio Navarese Search for more papers by this author , Thomas NguyenThomas Nguyen Search for more papers by this author , Marcus OngMarcus Ong Search for more papers by this author , Andrew PadkinAndrew Padkin Search for more papers by this author , Edison Ferreira de PaivaEdison Ferreira de Paiva Search for more papers by this author , Rod S. PassmanRod S. Passman Search for more papers by this author , Tommaso PellisTommaso Pellis Search for more papers by this author , John J. PicardJohn J. Picard Search for more papers by this author , Rachel ProutRachel Prout Search for more papers by this author , Morten PytteMorten Pytte Search for more papers by this author , Renee D. ReidRenee D. Reid Search for more papers by this author , Jon RittenbergerJon Rittenberger Search for more papers by this author , Will RossWill Ross Search for more papers by this author , Sten RubertssonSten Rubertsson Search for more papers by this author , Malin RundgrenMalin Rundgren Search for more papers by this author , Sebastian G. RussoSebastian G. Russo Search for more papers by this author , Tetsuya SakamotoTetsuya Sakamoto Search for more papers by this author , Claudio SandroniClaudio Sandroni Search for more papers by this author , Tommaso SannaTommaso Sanna Search for more papers by this author , Tomoyuki SatoTomoyuki Sato Search for more papers by this author , Sudhakar SatturSudhakar Sattur Search for more papers by this author , Andrea ScapigliatiAndrea Scapigliati Search for more papers by this author , Richard SchillingRichard Schilling Search for more papers by this author , Ian SeppeltIan Seppelt Search for more papers by this author , Fred A. SeverynFred A. Severyn Search for more papers by this author , Greene ShepherdGreene Shepherd Search for more papers by this author , Richard D. ShihRichard D. Shih Search for more papers by this author , Markus SkrifvarsMarkus Skrifvars Search for more papers by this author , Jasmeet SoarJasmeet Soar Search for more papers by this author , Keiichi TadaKeiichi Tada Search for more papers by this author , Sara TararanSara Tararan Search for more papers by this author , Michel TorbeyMichel Torbey Search for more papers by this author , Jonathan WeinstockJonathan Weinstock Search for more papers by this author , Volker WenzelVolker Wenzel Search for more papers by this author , Christoph H. WieseChristoph H. Wiese Search for more papers by this author , Daniel WuDaniel Wu Search for more papers by this author , Carolyn M. ZelopCarolyn M. Zelop Search for more papers by this author , David ZidemanDavid Zideman Search for more papers by this author and Janice L. ZimmermanJanice L. Zimmerman Search for more papers by this author Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.971051Circulation. 2010;122:S345–S421Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Cricoid PressureALS-CPR&A-007B”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access. The topics reviewed by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force are grouped as follows: (1) airway and ventilation, (2) supporting the circulation during cardiac arrest, (3) periarrest arrhythmias, (4) cardiac arrest in special circumstances, (5) identifying reversible causes, (6) postresuscitation care, (7) prognostication, and (8) organ donation. Defibrillation topics are discussed in Part 6.The most important developments and recommendations in advanced life support (ALS) since the 2005 ILCOR review are as follows: The use of capnography to confirm and continually monitor tracheal tube placement and quality of cardiopulmonary resuscitation (CPR).More precise guidance on the control of glucose in adults with sustained return of spontaneous circulation. Blood glucose values >180 mg/dL (>10 mmol/L) should be treated and hypoglycemia avoided.Additional evidence, albeit lower level, for the benefit of therapeutic hypothermia in comatose survivors of cardiac arrest associated initially with nonshockable rhythms.Recognition that many of the accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia. There is inadequate evidence to recommend a specific approach to prognosticating poor outcome in post–cardiac arrest patients treated with therapeutic hypothermia.The recognition that adults who progress to brain death after resuscitation from out-of-hospital cardiac arrest should be considered for organ donation.The recommendation that implementation of a comprehensive, structured treatment protocol may improve survival after cardiac arrest.Airway and VentilationConsensus conference topics related to the management of airway and ventilation are categorized as (1) basic airway devices, (2) cricoid pressure, (3) advanced airway devices, (4) confirmation of advanced airway placement, (5) oxygenation, and (6) strategies for ventilation.Basic Airway DevicesOropharyngeal and Nasopharyngeal AirwaysALS/BLS-CPR&A-080BConsensus on ScienceDespite frequent successful use of nasopharyngeal and oropharyngeal airways in the management of nonarrest patients, there are no published data on the use of these airway adjuncts during CPR in humans. When bag-mask ventilation was undertaken with an oral airway and compared with no oral airway, 1 study in anesthetized patients demonstrated higher tidal volumes (LOE 5).1One study of nasopharyngeal airways in anesthetized patients showed that nurses inserting nasopharyngeal airways were no more likely than anesthesiologists to cause nasopharyngeal trauma (LOE 5).2 One study showed that the traditional methods of sizing a nasopharyngeal airway (measurement against the patient's little finger or anterior nares) do not correlate with the airway anatomy and are unreliable (LOE 5).3 In 1 report, insertion of a nasopharyngeal airway caused some airway bleeding in 30% of cases (LOE 5).4 Two case reports reported inadvertent intracranial placement of a nasopharyngeal airway in patients with basal skull fractures (LOE 5).5,6Treatment RecommendationOropharyngeal and nasopharyngeal airways have long been used in cardiac arrest, despite never being studied in this clinical context. It is reasonable to continue to use oropharyngeal and nasopharyngeal airways when performing bag-mask ventilation in cardiac arrest, but in the presence of a known or suspected basal skull fracture an oral airway is preferred.Cricoid PressureALS-CPR&A-007BIn adults and children during ventilation and intubation, does the application and maintenance of cricoid pressure, compared to no cricoid pressure, reduce the incidence of aspiration?Consensus on ScienceNo studies addressing the use of cricoid pressure during cardiac arrest were identified. All the identified studies were conducted under anesthesia or in awake volunteers, cadavers, or manikins. (All studies are therefore LOE 5 for cardiac arrest.) Cricoid pressure in nonarrest patients may, to some extent, protect the airway from aspiration, but it may also impede ventilation or interfere with insertion of an advanced airway.The effect of cricoid presssure on gastric inflation during bag-mask ventilation was examined by 2 adult (LOE 17; LOE 28) and 2 pediatric studies (LOE 2).9,10 All showed less gastric inflation with cricoid pressure than without, although all of the studies used ventilation volumes higher than those recommended in cardiac arrest.Nine studies in nonarrest adult subjects undergoing anesthesia showed that cricoid pressure impairs ventilation in many patients, increases peak inspiratory pressures, and causes complete obstruction in up to 50% of patients, depending on the amount of cricoid pressure (in the range of recommended effective pressure) that is applied (LOE 17,11–13; LOE 214; LOE 48,15–17).One study in anesthetized patients determined that cricoid pressure prevents correct placement and ventilation with the laryngeal tube (LT) (LOE 1).18 Eight studies in anesthetized adults showed that when cricoid pressure was used before insertion of a laryngeal mask airway (LMA), there was a reduced proportion of LMAs correctly positioned, an increased incidence of failed insertion, and impaired ventilation once the LMA had been placed (LOE 119–23; LOE 224–26). No significant impairment to tracheal intubation was found by 4 LOE-1 studies performed in anesthetized patients,27–30 while 7 LOE-1 studies19,31–36 and 1 LOE-2 study37 did show impairment of intubation with increased time to intubation and decreased intubation success rates. One cadaver study demonstrated a worse laryngoscopic view with the application of cricoid pressure (LOE 5).38Twenty-one manikin studies demonstrated that many providers applied less cricoid pressure than has been shown to be effective (in cadaver studies) whereas many other providers applied more pressure than has been shown to be necessary (and far in excess of the amount of pressure shown to impede ventilation) (LOE 5).39–59 Four of those studies determined that performance can be improved with training (although many cricoid pressure applications following training remain outside recommended effective pressures).54–56,59 No study examined if cricoid pressure performance to the required standard could be maintained beyond the immediate post-training period.Cricoid pressure prevented movement of liquid from the esophagus into the pharynx in 5 cadaver studies (LOE 5)60–64; however, in 1 LOE-2 study65 of 4891 obstetric patients undergoing anesthesia, no significant difference was observed in regurgitation rates between patients who received cricoid pressure and those who did not. There are case reports where prevention of aspiration is ascribed to the application of cricoid pressure (LOE 4)66–68 and other case reports documenting that aspiration occurs despite the application of cricoid pressure (LOE 4).69–73Treatment RecommendationThe routine use of cricoid pressure to prevent aspiration in cardiac arrest is not recommended. If cricoid pressure is used during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or placement of an advanced airway.Knowledge GapsFuture research should address whether cricoid pressure prevents regurgitation and aspiration, the pressure required to be effective, and effectiveness trials evaluating if it can be done well by responders to a cardiac arrest.Advanced Airway DevicesThe tracheal tube was once considered the optimal method of managing the airway during cardiac arrest. There is considerable evidence that without adequate training or ongoing skills maintenance, the incidence of failed intubations and complications, such as unrecognized esophageal intubation or unrecognized dislodgement, is unacceptably high.74–79 Prolonged attempts at tracheal intubation are harmful if associated with interruption of chest compressions because this will compromise coronary and cerebral perfusion. Alternatives to the tracheal tube that have been studied during CPR include the bag-mask and supraglottic airway devices, such as the laryngeal mask airway, esophageal-tracheal combitube and laryngeal tube, among others. Studies comparing supraglottic airway to tracheal intubation have generally compared insertion time and ventilation success rates. No study has shown an effect of the method of ventilation on survival. There are no data to support the routine use of any specific approach to airway management during cardiac arrest. The quality of CPR with various advanced airways was not included in the review for 2010. The best technique depends on the precise circumstances of the cardiac arrest, local guidelines, training facilities, and the competence of the rescuer.Timing of Advanced Airway PlacementALS-SAM-062AIn adult cardiac arrest (prehospital or in-hospital), does an alternate timing for advanced airway insertion (eg, early or delayed), as opposed to standard care (standard position in algorithm), improve outcome (eg, return of spontaneous circulation [ROSC], survival)?Consensus on ScienceOne registry study evaluated the impact of timing of advanced airway placement during 25,006 in-hospital cardiac arrests (LOE 2).80 In this study, earlier time to invasive airway (<5 minutes) was associated with no improvement in ROSC but improved 24-hour survival (NNT=48). In an urban out-of-hospital setting, intubation in <12 minutes was associated with better survival than intubation ≥13 minutes.81 In an out-of-hospital urban and rural setting, patients intubated during resuscitation had better survival than patients not intubated82; whereas in an in-hospital setting, patients requiring intubation during CPR had worse survival.83 A recent study found that delayed tracheal intubation bundled 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 adult, witnessed, ventricular fibrillation (VF)/ventricular tachycardia (VT).84 The independent contribution of the timing of the advanced airway was not available in the study.Treatment RecommendationThere is inadequate evidence to define the optimal timing of advanced airway placement during cardiac arrest.Knowledge GapsTo advance the science in this area we need to define what is “early” and what is “delayed” placement of advanced airways, the superiority of advanced airways over simple bag-mask ventilation, and whether there is any significant difference between the advanced airway types.Advanced Airway Versus Ventilation With Bag-MaskALS/BLS-CPR&A-088A, ALS/BLS-CPR&A-088BIn adult cardiac arrest (prehospital, out-of-hospital cardiac arrest [OHCA], in-hospital cardiac arrest [IHCA]), does the use of supraglottic devices, compared with bag-mask alone for airway management, improve any outcomes (eg, increase ventilation, increase oxygenation, reduce hands-off time, allow for continuous compressions, and/or improve survival)?Consensus on ScienceA retrospective case series (LOE 4) comparing a laryngeal mask airway with bag-mask ventilation in cardiac arrest patients demonstrated a regurgitation rate of 3.5% with use of a laryngeal mask airway and 12.4% with use of bag-mask ventilation.85 When a variety of supraglottic airway devices were compared with bag-mask ventilation in manikin models, 6 studies showed improved ventilation and a decrease in gastric inflation (LOE 5).86–91 One pseudorandomized and 1 nonrandomized clinical trial (LOE 2) found no difference in arterial blood gas values or survival rates when a variety of supraglottic airway devices were compared to bag-mask ventilation.92,93 Three studies performed in manikin models of cardiac arrest (LOE 5)94–96 found that, compared with a bag-mask, the use of a single-use, disposable laryngeal tube to provide ventilation may decrease no-flow times.Treatment RecommendationA supraglottic airway device may be considered by healthcare professionals trained in its use as an alternative to bag-mask ventilation during cardiopulmonary resuscitation.Knowledge GapsFurther data are needed on the adequacy of ventilation with the various supraglottic airway devices if chest compressions are not interrupted; also needed are comparisons of the various supraglottic airway devices with each other and with bag-mask ventilation when used clinically by inexperienced and by experienced providers.Tracheal Intubation Versus the Combitube/Laryngeal Mask AirwayALS/BLS-CPR&A-079A, ALS/BLS-CPR&A-079BConsensus on ScienceNine studies compared a variety of supraglottic airway devices with the tracheal tube during cardiac arrest (LOE 197; LOE 298–105) and a further 6 studies compared a variety of supraglottic airway devices with the tracheal tube in patients undergoing anesthesia (LOE 5).106–111 Overall in these studies the supraglottic airway device performed as well as, or better than, the tracheal tube with respect to successful insertion and/or time to tube insertion or to ventilation. One study retrospectively compared outcomes in cardiac arrest patients treated with an esophageal-tracheal-combitube or tracheal tube and found no difference in ROSC, survival to admission, or survival to discharge (LOE 2).104 One study compared survival in cardiac arrests managed with a laryngeal mask airway with an historical control group of cardiac arrests managed with a tracheal tube and found that ROSC was significantly higher in the study period (61% versus 36%) (LOE 3).105Eight manikin studies with simulated cardiac arrest (LOE 5)89,90,96,112–116 and 8 manikin studies without simulated cardiac arrest showed that successful insertion rates and/or time to insertion or to ventilation for a variety of supraglottic airway devices were as good, or better than, for the tracheal tube (LOE 5).117–124Nine studies documented that when a supraglottic airway device is used as a rescue airway after failed tracheal intubation, most patients can be ventilated successfully with the supraglottic airway device (LOE 298,99,103; LOE 3125–128; LOE 5107,129).Two studies performed while wearing anti-chemical protective clothing, 1 randomized crossover trial on anesthetized patients, and a pseudorandomized study on manikins found increased time to tracheal tube insertion but not to laryngeal mask airway insertion (LOE 5).108,117Three manikin studies comparing a supraglottic airway device with the tracheal tube during ongoing chest compressions demonstrated decreased time to intubation with the supraglottic airway device, as well as reduced no flow time (LOE 5).96,112,115 One nonrandomized manikin study found that chest compressions caused only a minor increase in time to tracheal intubation but not to supraglottic airway device insertion (LOE 5).114Treatment RecommendationHealthcare professionals trained to use supraglottic airway devices may consider their use for airway management during cardiac arrest and as a backup or rescue airway in a difficult or failed tracheal intubation.Knowledge GapsThe adequacy of ventilation with supraglottic airway devices during uninterrupted chest compressions is unknown. The performance of the various supraglottic airway devices should be compared with each other and with the tracheal tube when used in cardiac arrest. Use of the supraglottic airway devices by providers of differing experience should also be studied.Confirming Advanced Airway PlacementExhaled Carbon Dioxide Detection and Esophageal Detection DevicesALS-CPR&A-008A, ALS-CPR&A-008BIn adult cardiac arrest (out-of-hospital [OHCA], in-hospital [IHCA]), does the use of devices (eg, CO2 detection device, CO2 analyzer, or esophageal detector device), compared with usual management, improve the accuracy of diagnosis of airway placement?Consensus on ScienceTwo studies of waveform capnography (LOE D2) to verify tracheal tube position in victims of cardiac arrest after intubation demonstrated 100% sensitivity and 100% specificity in identifying correct tracheal tube placement.130,131 One of these studies included 246 intubations in cardiac arrest with 9 esophageal intubations,130 and the other included 51 cardiac arrests with an overall esophageal intubation rate of 23%,131 but it is not specified how many of these occurred in the cardiac arrest group. Three studies (LOE D1)132–134 with a cumulative total of 194 tracheal and 22 esophageal tube placements demonstrated an overall 64% sensitivity and 100% specificity in identifying correct tracheal tube placement when using the same model capnometer (no waveform capnography) on prehospital cardiac arrest victims. The sensitivity may have been adversely affected by the prolonged resuscitation times and very prolonged transport times of many of the cardiac arrest victims studied. Intubation was performed after arrival at hospital and time to intubation averaged more than 30 minutes.Studies of colorimetric end-tidal CO2 (ETCO2) detectors (LOE D2135,136; LOE D4137–139; LOE D5140,141), the syringe aspiration esophageal detector device (LOE D1133; LOE D4142), the self-inflating bulb e
