Nov 102018

Well-done bag-mask ventilation can produce adequate gas exchange for the vast majority of cardiac arrest patients, but does not provide a secure airway and is physically taxing. Patients in cardiac arrest undergoing CPR tend to immediately receive bag-mask ventilation, which is often interrupted to perform endotracheal intubation.

To facilitate intubation, chest compressions may also be interrupted or reduced in quality; this could result in diminished organ perfusion during CPR. A previous observational study raised the possibility that intubation during cardiac arrest might lead to worse outcomes. A large registry study in Japan also associated intubation with worse outcomes in cardiac arrest.

A large randomized trial from Europe does not settle the question, supporting neither endotracheal intubation nor bag-mask ventilation as clearly superior for patients with out of hospital cardiac arrest, on their way to the hospital.

Authors randomized 2043 patients with out-of-hospital cardiac arrest in France and Belgium to either endotracheal intubation or  bag-mask ventilation. An emergency physician was present on the ambulance in all cases.

Equal numbers of patients in both groups (4%) had favorable functional survival at 28 days, the primary outcome. However, the 95% confidence interval did not exclude -1% (their threshold for noninferiority), rendering the results statistically inconclusive.

Patients getting bag-mask ventilation had significantly more episodes of gastric regurgitation (~15% vs ~8%) and failure to ventilate (~7% vs 2%), highlighting the clinical advantages for intubation to secure the airway.

A secure airway achieved through speedy, expert endotracheal intubation is undoubtedly preferable than prolonged bag-mask ventilation of a vomiting, aspirating cardiac arrest patient. However, if intubation is difficult or cannot be done without reducing the quality of CPR, well-done bag mask ventilation should not be seen as substandard care.

That said, bag-mask ventilation is often (usually?) done improperly or suboptimally. Here's one way to do it right (visit Dr. Reuben Strayer's Vimeo page or for more great resources):

Emergency Ventilation in 11 Minutes from reuben strayer on Vimeo.

Source: JAMA

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Intubation or bag-mask ventilation: Outcomes similar for cardiac arrest patients