Chapter 5 / Management of Ventilation

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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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that provided by endotracheal intubation and superior to bag-valve-mask ventilation; and

(c) have similar complication rates to endotracheal intubation. Additionally, alternative
airway devices can sometimes be used when tracheal intubation is not possible (1).
The amount of ventilation required during resuscitation is not well established. Although
the minute ventilation requirements may be decreased by a low cardiac output, the excess
load of carbon dioxide returning from ischemic tissue beds must be cleared by ventilation. Chest compressions alone do not generate adequate or consistent ventilation in
humans, even after intubation (2). In the resuscitation patient, 100% oxygen should be
started immediately using a bag-valve-mask. This should be followed rapidly by endotracheal intubation once skilled individuals arrive on scene. If intubation is unsuccessful,
then an alternative airway should be employed.
When a nonintubated patient is ventilated, the distribution of gas between the lungs
and stomach depends on the patients lower esophageal sphincter pressure, respiratory
mechanics (the respiratory system compliance and degree of airway obstruction), and the
technique of the rescuer performing basic life support (BLS; inspiratory flow rate, peak
airway pressure, and tidal volume). Accidental stomach inflation during CPR can elevate
intragastric pressure and lead to the cascade of regurgitation, aspiration, pneumonia, and
death even in the successfully resuscitated patient (3).
Ventilation has an impact on blood gases even at very low cardiac output states (4).
Hypoxia and hypercarbia have an independent adverse effect on resuscitation, and can
be corrected with appropriate ventilation. Adequate ventilation is important for return of
spontaneous circulation (5). Successful ventilation with rapid and uninterrupted chest
compressions significantly improves coronary perfusion during CPR (6) and this makes
successful defibrillation more likely (7).
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). Bystander CPR for the first 5 minutes has equivalent outcomes with or
without mouth-to-mouth ventilation (9). This suggests that airway control is most useful
when achieved in the first 56 minutes of CA.

INDICATIONS FOR ASSISTED VENTILATION

Rapid assessment of the patient allows for appropriate decision on airway management. Important considerations include adequacy of ventilation, airway patency, need for
neuromuscular blockade, cervical spine stability, safety of the technique, and the skill of
the operator (10).
Some patients are intubated for airway protection and others are intubated specifically
for failure of ventilation or oxygenation. Objective indicators of ventilatory status include
arterial blood gas, pulse oximetry, capnography, chest radiography, and spirometry. Methods to maintain an open airway range from BLS measures (e.g., head tiltchin lift) to
advanced airway techniques (e.g., endotracheal intubation). Medical providers should be
proficient in several techniques at each level of airway control. This allows the operator
to be flexible in the management of the airway as the situation demands.
Once a patient has been found to be unresponsive, and the emergency response system
has been activated, the airway needs to be assessed. First, the patient should be placed in
the supine position. If trauma is suspected, the cervical spine must be protected, and the
patient should be log rolled. The rescuer should open the airway and assess breathing by
looking for a chest rise, listening for exhaled breath, and feeling for air exchange at the

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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.

Head TiltChin Lift

Placing one hand on the patients forehead and the index and middle finger of the other
hand on the bony part of the chin performs the head tiltchin lift. The patients head is
rotated as the chin is lifted. This lifts the jaw and elevates the tongue off the back of the
pharynx, opening the airway.

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.

Basic Life Support Techniques

The first step is to open the airway, then look, listen, and feel for breathing. If the
patient is not breathing adequately, rescue breathing must be performed. The AHA recommends that lay rescuers check for signs of circulation (e.g., normal breathing, coughing, or normal movement in response to stimulation) rather than perform a pulse check
to determine if chest compressions should be administered. Trained health care providers are encouraged to check for a pulse. 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).

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. 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). This has led to consideration of removing mouth-tomouth ventilation guidelines from CPR (9). Current guidelines still recommend mouthto-mouth ventilation in out-of-hospital arrest, but recognize that basic CPR with chest

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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-Nose Rescue Breathing

Mouth-to-nose rescue breathing can be used when there are contraindications to mouthto-mouth breathing. Conditions such as anatomic abnormalities, trismus, or severe trauma
could prevent formation of an appropriate seal. The rescuer positions the patients head
in extension. One hand is placed on the forehead and the other lifts the mandible and
closes the mouth. The rescuers mouth is placed over the patients nose and a seal is
formed with the lips. The appropriate breaths are delivered, and the mouth is removed
from the patients nose to allow passive exhalation. It may be necessary to open the mouth
intermittently to allow complete exhalation.

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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Fig. 1. Example of a pocket shield device.

Fig. 2. Ventilation masks.

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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Fig. 3. Example of a typical bag-valve-mask assembly.

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. 3). The key to proper use of the bag-valve-mask
is to maintain a tight seal. There are different techniques depending on whether there is
a single operator or two operators.

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).

Oropharyngeal Airway Device

An oropharyngeal airway is a plastic or rubber device that can be inserted into a victims
mouth to elevate the tongue and create a path between the tongue and palate (Fig. 5). This
device should not be used on a patient who has an intact gag reflex. It is indicated in the
unresponsive or obtunded patient and can be used in conjunction with a bag-valve-mask
device.
To size an oropharyngeal airway, choose one that fits from the middle of the mouth to
the angle of the jaw. The airway is inserted by turning it 90 and inserting it halfway into
the mouth. Then rotate back 90 so that the bottom wraps around the back of the tongue.

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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.

Fig. 5. Oropharyngeal airways.

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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Fig. 6. Nasopharyngeal airways.

Nasopharyngeal Airway Device

A flexible tube designed to be inserted into the nares and extend to the base of the
tongue (Fig. 6). A nasopharyngeal airway can help maintain airway patency in an unconscious or obtunded patient but does not ensure patency without good head positioning.
This airway adjunct can be used in conjunction with a bag-valve-mask to facilitate ventilation. Nasopharyngeal airways can be used with patients that still have an intact gag
reflex.
To size a nasopharyngeal airway, choose a tube that extends from the tip of the nose
to the angle of the patients mandible. The diameter of the tube should approximate the
diameter of the nares. The tube is lubricated and inserted into the nares so that the beveled
tip is midline, and the curve of the tube follows the curvature of the patients airway.

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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Fig. 7. Examples of laryngoscope handles and blades.

Fig. 8. Miller and MacIntosh laryngoscope blades.

The laryngoscope is an apparatus designed to permit direct visualization of the larynx

and facilitate endotracheal intubation through direct laryngoscopy (Figs. 7 and 8). There
are two basic blade designs. The first is the curved blade, typified by the MacIntosh blade.
The second type is the straight blade such as the Miller or Wisconsin blades (Welch Allyn,
Skaneateles Falls, NY). Various sizes are available for adult and pediatric use. The main

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Fig. 9. Endotracheal tubes.

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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Fig. 10. Example of a capnograph.

Fig. 11. Bulb esophageal detector.

Endotrol Endotracheal Tube

Nasotracheal intubation is an alternative technique in which the ETT or Endotrol tube
(Mallinckrodt Critical Care Inc., St. Louis, MO) is inserted through the nares down into
the trachea. 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. Usually the
tube size chosen is slightly smaller (by 0.51.0 mm) than would be used for endotracheal
intubation. As nasotracheal intubation requires that the patient be spontaneously breathing, it will not be considered further in this chapter.

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Fig. 12. Syringe aspirator.

Fig. 13. Combitubes.

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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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.

Laryngeal Mask Airway

The LMA was introduced into clinical practice in 1988. The LMA is a triangular
shaped inflatable pink silicon laryngeal mask (Fig. 14). The mask has an opening in the
middle that prevents accidental obstruction of the tube by the tip of the epiglottis. Gastric
distention is minimized because excess pressure is vented upward around the LMA
instead of into the esophagus.
The LMA can be used when the patient is unresponsive or the protective reflexes have
been sufficiently depressed. The mask is deflated to form a flat wedge that will pass
behind the tongue and behind the epiglottis. The LMA is blindly inserted into the pharynx
with the point of the triangle in the esophagus and the mask over the laryngeal inlet. The
mask is then inflated and seals off the laryngeal inlet. The LMA is not a definitive airway,
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. It can be used as an adjunct in the difficult airway when primary endotracheal
intubation has been attempted unsuccessfully.
TECHNIQUE
Completely deflate the LMA until the cuff forms a smooth spoon shape without any
wrinkles. Hold the LMA like a pen, 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. The index finger can be used to assist in guiding the LMA behind the
tongue. Advance the LMA into the hypopharynx until resistance is felt. Inflate the cuff
with enough air to obtain a seal. Normal intracuff pressures are around 60 cm H2O.

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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Fig. 14. Laryngeal mask airway.

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