Cardiac arrest can occur suddenly and is a leading cause of death worldwide. Performing high-quality CPR immediately is essential to maintain blood flow to the heart and brain, increasing the chances of survival. While standard CPR relies on cycles of chest compressions and rescue breaths, the approach changes significantly when an advanced airway is used.
An advanced airway, such as an Endotracheal Tube (ETT) or Supraglottic Airway (SGA), secures the patient’s airway, allowing for continuous chest compressions while ventilations are delivered independently. This method improves oxygen delivery, reduces the risk of aspiration, and enables more efficient management of medications and defibrillation during resuscitation. Correct placement, monitoring, and teamwork are essential for effective advanced-airway CPR.
This blog explains how CPR is performed differently with an advanced airway, covering airway placement, team roles, ventilation techniques, and monitoring. It also highlights when to use or avoid advanced-airway CPR and common mistakes to prevent, ensuring rescuers provide effective, life-saving care.
What Is An Advanced Airway in CPR?
An advanced airway in CPR is a medical device used to secure the airway and ensure consistent, effective ventilation during cardiac arrest. Unlike basic airway methods such as mouth-to-mouth or a standard bag-valve mask, an advanced airway establishes a controlled and protected pathway for air to reach the lungs, even during high-quality chest compressions.
Common advanced airway types include Endotracheal Tubes (ETT) and Supraglottic Airways (SGA). An ETT is inserted through the mouth and positioned directly in the trachea, offering the highest level of airway protection. SGAs, such as the I-gel or Laryngeal Mask Airway (LMA), sit above the vocal cords and can be placed quickly in emergency settings. Some patients may also have a tracheostomy tube, which enters the airway through a surgically created opening in the neck.
How Is CPR Different With an Advanced Airway in Place?
When an advanced airway is in place, CPR focuses on continuous chest compressions without pausing for breaths. Rescue breaths are given separately, allowing uninterrupted circulation and more efficient oxygen delivery during resuscitation.
Here is a quick comparison of CPR with and without an advanced airway.
1. Airway Placement
In standard CPR, no airway placement is required. However, CPR with an advanced airway requires the airway to be positioned before chest compressions continue uninterrupted. This can be achieved using an Endotracheal Tube (ETT) or a Supraglottic Airway (SGA). Correct placement is confirmed by observing chest rise with each ventilation, listening for breath sounds, and, when available, using capnography.
2. Team Roles
Standard CPR can be performed by a single rescuer, but CPR with an advanced airway requires at least two rescuers. One rescuer focuses on delivering continuous chest compressions, while the other manages the advanced airway and provides ventilations. It is not feasible for a single rescuer to maintain uninterrupted compressions while simultaneously managing an advanced airway, making teamwork essential for effective resuscitation.
3. Uninterrupted Chest Compressions
In standard CPR, chest compressions are paused every 30 cycles to provide 2 rescue breaths. However, chest compressions are performed continuously without pause for breaths when an advanced airways are in place. Compressions should be performed at a rate of 100-120 per minute, with adequate depth and full chest recoil. Continuous compressions maximize blood flow to the heart and brain, increasing the chances of successful resuscitation.
4. Independent (Asynchronous) Ventilation Delivery
With an advanced airway, ventilations are delivered asynchronously, meaning they are given independently while chest compressions continue. When an advanced airway is in place, one breath is provided every 6 seconds, or approximately 10 breaths per minute. Ventilations are typically delivered using a bag-valve-mask device attached to the advanced airway or a mechanical ventilator.
In contrast, CPR without an advanced airway relies on mouth-to-mouth breaths delivered directly by the rescuer. In conventional CPR, two rescue breaths are given after every 30 compressions, while in hands-only CPR, no rescue breaths are administered.
5. Monitoring Ventilation
During CPR with an advanced airway, continuous monitoring of ventilation is essential to ensure effective oxygen delivery. Rescuers should observe visible chest rise with each breath and confirm that the airway remains securely in place. When available, Capnography (End-tidal CO₂ Monitoring) provides real-time feedback on ventilation effectiveness and overall CPR quality.
Proper monitoring helps detect airway displacement or inadequate ventilation early, allowing immediate corrective action to maintain optimal resuscitation outcomes. In contrast, CPR without an advanced airway does not have a reliable system for monitoring ventilation, making it more difficult to assess the effectiveness of rescue breaths.
When Should CPR Be Performed with an Advanced Airway?
Advanced airway CPR is not necessary for every cardiac arrest situation. It is typically reserved for cases where maintaining effective oxygenation and circulation requires more than basic CPR techniques. The use of an advanced airway ensures continuous compressions while providing reliable ventilation, which can be critical in certain scenarios.
1. Prolonged Cardiac Arrest
In cases where resuscitation efforts are expected to continue for an extended period, an advanced airway allows continuous compressions and consistent oxygen delivery without repeated interruptions for breaths.
2. High Risk of Aspiration
Patients who are at risk of vomiting, have blood or secretions in the airway, or have a compromised airway benefit from advanced airway placement to prevent aspiration and protect the lungs.
3. Severe Trauma or Respiratory Failure
Individuals with major injuries, compromised breathing, or respiratory arrest may require advanced airway management to ensure adequate oxygenation and airway protection during resuscitation.
4. Team-Based or Hospital Settings
Advanced-airway CPR is most commonly used when multiple trained rescuers are present, such as in hospitals or organized emergency response teams. Clear role assignment allows one rescuer to focus on compressions while another manages the airway and ventilation.
5. Need for Medication Administration
When drugs must be delivered during CPR, an advanced airway allows medications to be administered via IV or IO routes without interrupting compressions, improving the efficiency of life-saving interventions.
When Should an Advanced Airway Not Be Used During CPR?
While advanced airways can be life-saving, they are not appropriate in every situation. Understanding when not to use one helps maintain high-quality CPR and reduces the risk of complications.
1. Cervical Spine Injury
Extra caution is needed when placing an advanced airway in patients with suspected cervical spine injuries. Improper technique or excessive neck movement can worsen spinal damage, making airway management potentially dangerous.
2. Intact Gag Reflex
Oropharyngeal airways (OPAs) should not be inserted in patients who still have a gag reflex. Inserting an airway in these patients can trigger gagging, vomiting, or increase the risk of aspiration.
3. Lack of Skilled Personnel
Advanced airway placement requires training and experience. If trained providers are not available, attempting to place an advanced airway can delay CPR and increase the risk of harm. Basic CPR techniques or hands-only compressions are safer in such situations.
4. Difficult Anatomy or Trauma
Severe facial trauma, swelling, or airway obstruction may make advanced airway placement unsafe or impossible. Attempting placement under these conditions can worsen injuries and delay life-saving compressions.
5. Single Rescuer Scenarios
If only one rescuer is available, placing an advanced airway may interrupt compressions for too long. In these cases, hands-only CPR or basic rescue breaths are recommended until additional help arrives.
What Are the Common Mistakes to Avoid When Using an Advanced Airway?
Even experienced rescuers can make errors during advanced-airway CPR. Avoiding these mistakes is crucial for maintaining high-quality compressions, effective ventilation, and patient safety.
1. Improper Airway Placement
Placing an endotracheal tube or supraglottic airway incorrectly can result in inadequate oxygen delivery, airway obstruction, or even ventilation of the stomach. Always confirm placement by checking chest rise, breath sounds, and, when available, using capnography.
2. Over-Ventilation
Delivering breaths too quickly or with excessive volume can cause gastric inflation, reduce venous return, and compromise cardiac output. The recommended ventilation rate is one breath every 6 seconds (10 per minute), with each breath lasting about one second and producing a visible chest rise.
3. Failing to Monitor Ventilation
Neglecting to monitor airway effectiveness can lead to hypoxia or inadequate ventilation. Continuous observation of chest rise, breath sounds, and capnography (if available) is essential to ensure the airway remains secure and functioning properly.
4. Poor Team Coordination
Advanced-airway CPR requires clear roles: one rescuer for compressions and another for ventilation. Confusion or overlapping responsibilities can lead to interruptions, improper ventilations, or delays in drug administration and defibrillation.
5. Ignoring Post-Resuscitation Care
Once circulation is restored, failing to manage the airway properly can lead to hypoxia, aspiration, or respiratory complications. Advanced airway management should continue until the patient is stable or transitioned to definitive airway support in a hospital.
Strengthen Your CPR Skills With Advanced Airway Knowledge
CPR with an advanced airway allows continuous chest compressions while delivering controlled, effective ventilations. It improves oxygenation, reduces the risk of aspiration, and enables efficient medication delivery during resuscitation. Proper placement, team coordination, and careful monitoring are essential. Advanced-airway CPR should be performed by trained personnel in appropriate situations to maximize survival and recovery during cardiac arrest.
Learning how to perform CPR with an advanced airway correctly can make the difference between life and death in an emergency. To build these critical skills and be fully prepared, enhance your lifesaving abilities with CPR VAM. As an AHA-certified training center, we offer expert-led CPR, BLS, ACLS, and PALS courses across the U.S. Gain hands-on experience, learn at your own pace, and get certified instantly.
