@ILCOR 2020: Let's Put the Supraglottic Airway First!

​The International Liaison Committee on Resuscitation has published the last guidelines for advanced cardiac life support (ACLS) on resuscitation ILCOR in 2015. Usually, these statements are updated every five years, but 'Circulation' has now published an AHA (American Heart Association) focused update due to an increased number of studies looking at ACLS-specific interventions.


These updates are focused on three specific areas:

1. Advanced airway management
2. Vasopressors
3. Extracorporeal cardiopulmonary resuscitation ECPR

​No News in regards to Vasopressors and ECPR

Vasopressors in Cardiac Arrest

• Epinephrine (aka Adrenaline) should be administered to patients with cardiac arrest (Class I; Level of Evidence B-R)
• It is reasonable to administer 1mg every 3 to 5 minutes (Class IIa; Level of Evidence C-LD)
• High-dose epinephrine is not recommended for routine use in cardiac arrest

The bottom line:​ Great, these recommendations are no real news and do not change current guidelines at all.


Extracorporeal Cardiopulmonary Resucitation ECPR

• There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest AND ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers

The bottom line: ECPR is not for on the roads and remains an exception in general.



Advanced Airway Management

Taking recent evidence into account the updated guidelines 2019 conclude:
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• Either BMV or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting (Class 2b; Level of Evidence B-R).
• If an advanced airway is used, the SGA can be used for adults with OHCA in settings with low tracheal intubation success rate or minimal training opportunities for ETT placement (Class 2a; Level of Evidence B-R).
• If an advanced airway is used, either the SGA or ETT can be used for adults with OHCA in settings with high tracheal intubation success rates or optimal training opportunities for ETT placement (Class 2a; Level of Evidence B-R).
• If an advanced airway is used in the in-hospital setting by expert providers trained in these procedures, either the SGA or ETT can be used (Class 2a; Level of Evidence B-R).
• Frequent experience or frequent retraining is recommended for providers who perform ETI (Class 1; Level of Evidence B-NR).
• Emergency medical services systems that perform prehospital intubation should provide a program of ongoing quality improvement to minimize complications and to track overall SGA and ETT placement success rates (Class 1; Level of Evidence C-EO).​

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We Suggest: Put the Supraglottic Airway First!

​In regards to these updated guidelines, the necessity of optimal cardiopulmonary resuscitation (CPR) during resuscitation and practical considerations, it seems reasonable to put the supraglottic airway (SGA) to the very top of airway management!
​Here is why:

• During resuscitation maintaining circulation and therefore vital coronary perfusion pressure (CPP) is the mainstay of success
• BMV requires interruptions of CRP (30:2),  this is deleterious!
• Avoiding unnecessary interruption of compressions remains therefor a top priority. Interruptions result in the sudden collapse of CPP, which will hinder successful CPR ​​

Avoiding interruptions is the key to successful CRP and therefore survival

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• Bag mask ventilation (BMV) can be quite tricky, especially when performed by untrained personnel. 
• BMV is NOT a secure airway; the risk of aspiration is significant!

On the other hand

• While providing a 'secure' airway, successful endotracheal intubation requires skilled hands and regular training
• ETI's are mostly outside the scope of practice among many doctors, nursing staff or paramedics
• Intubations under CPR conditions are never easy and might be even more challenging out-of-hospital
• Again, CPR is often interrupted to provide optimal conditions for endotracheal intubation

It, therefore, seems plausible to put the supraglottic airway first. Not only first as a choice of airway management, but also one of the first things to do:

• Placing a supraglottic airway (SGA) is simple and straight forward. Anyone can learn this procedure in a short time. We teach ICU doctors and nurses successfully on how to use non-inflatable supraglottic airways (e.g. the i-Gel device) for CPR.
• Placing an SGA is easier than simple bag-mask ventilation (BMV)!
• An SGA allows continuous compressions and ventilation simultaneously - no need for deleterious interruptions
• An SGA protects the airway from aspiration fairly well - some devices even allow the introduction of a small suction catheter into the stomach
• Moreover, if required, endotracheal intubation can still be performed by using a bougie through the SGA. This provides another option to perform ETI without interruptions of chest compressions.
• And last but not least, SGA's allow continuous measurement of end-tidal CO2 ​

Summary of Evidence and Experience on Airway-Devices used for CRP

The International Liaison Committee on Resuscitation (ILCOR) has again carried together all evidence and recently published more than 50 new ILCOR treatment recommendations and scoping reviews. You can find these documents right here: https://costr.ilcor.org 

This website provides an excellent systematic review of the Advanced Airway Management during Adult Cardiac Arrest, containing references to all relevant evidence available.

​Based on this and given the experience from everyday clinical practice, it would be worth considering supplementing the recommendations as follows.

- For resuscitation performed by health care professionals (physicians, nurses, paramedics), the use of a supraglottic airway (ideally non-inflatable) as soon as possible is recommended.



2019 AHA Focused Updated on Adult Cardiovascular Life Support

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