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Four Reasons Why Intubation During Cardiac Arrest Doesn't Always Work

In “Intubation for Cardiac Arrest Patients,” author Samuel M. Galvagno Jr., DO, PhD, identifies several reasons why intubation has not been shown to positively impact outcomes for cardiac arrest patients.

First, intubation during cardiac arrest is not always straightforward, and in at least one study, 30% of patients required more than one attempt.(1)

Second, the learning curve to attain competence is steep—one study suggests up to 60 intubations are required to become proficient—and in some systems, EMS providers do not have opportunities maintain this skill.(2) As Nable et al write, “maintaining proficiency in endotracheal intubation is a significant barrier for many prehospital providers.”(3) In Wang et al, intubation success by medics was only 78%.(1)

Third, intubation is followed by positive pressure ventilation (PPV), and PPV has been shown to decrease preload, lower cardiac output, and negatively impact the effectiveness of chest compressions.(3)

Fourth, intubation may require interruption of chest compressions, and this has clearly been linked with worse outcomes.(4) For the abovementioned reasons, in some countries, such as the U.K., a case has been made for abandoning intubation altogether in cardiac arrest.(5)

1. Wang HE, Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation? AcadEmerg Med. 2006;13:373–377.

2. West MR, Jonas MM, Adams AP, et al. A new tracheal tube for difficult intubation. Br J Anaesth. 1996;76:673–679.

3. Nable JV, Lawner BJ, Stephens CT. Airway management in cardiac arrest. Emerg Med Clin N Am. 2012;30:77–90.

4. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335–340.

5. Deakin CD, Clarke T, Nolan J. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group. Emerg Med J. 2008;27:226–233.


  1. While all the points noted are technically correct, let’s look at some other information.
    *Most successful cardiac arrest resuscitations occur with only cpr and shock.
    *Positive pressure ventilation will not decrease cardiac output, IF the rate/volume are not excessive. We were reflexively taught to put a minimum of 800 cc of air into each delivered breath and the 12/min that was the old standard was more likely 20. If we limit the volume to just enough to begin to move the chest wall AND limit the rate to 8/min or less AND not interrupt chest compressions, the negative effects of positive pressure ventilations can be negated.
    * Supraglottic airways (king, etc…) decrease venous return from brain, causing poorer neurological outcomes in resuscitated population….SOOOO, ETI is still the preferred method when an advanced airway is needed.
    *Learning curve for ETI is steep only in those who can’t put the tube in the hole. This is mostly a systems issue, rather than a condemnation of the practice.
    *Many failed intubations occured because of the lack of preparation and the silly rule of holding one’s breath while trying to “get the tube”, thus hurrying the intubation. Couple this with poor positioning of the patient and you get failure. Position the patient for success and in cardiac arrest, stop worrying about how much time the attempt takes, as long as chest compressions continue uninterruptedly.

    Mastery of this skill, like any other is obtained through practice. It is incumbent on you and your agency(ies) to ensure that all providers are adequatedly trained AND practiced. If this does not occur, it is, again, a SYSTEM problem.
    RP Breese, CCEMTP, FP-C

  2. Christopher D'Angelo

    I am really sick of this argument. This skill has been nothing but essential in my 15 years of para medicine. Stop allowing incapable canidates become paramedics. People are putting forth unearned trust into the 911 system and we are allowing people who are not capable respond. Train these canidates appropriately and start payin to retain the paramedics who do this job well and maybe instead of taking skills away, newer advanced skills will be incorporated. Enough about removing intubation! I have over 100 successful intubations, 10 successful walk out of the hospital saves.

    • I don’t think that we’ve established that the skill is essential. There are very few situations where, in a pre-hospital setting, intubation is demonstrable better than other techniques. Our focus MUST be on doing whatever improves patient outcomes. I think that using “tube through the hole” as the measure of success is misguided. Improved outcomes should be the benchmark, and if intubation worsens this, then it should not be performed. Doing the most good for the patient is our duty and clinging to a skill that impedes this is indefensible.

    • lol 100 intubations and 10 walk out saves? those are terrible numbers guy….. i may have only been doing this for a short time…..but in the world of not what you do to your pt but what you do for them, some of us have only tubed once, the rest king airways with good cpr and cold fluids….out of the 20 ive been on 8 have walked out …..just saying sounds like you need to read up ….the future is in simplified cardiac arrest…soprry

  3. What is the success rate of intubation in the ER setting? What is the survival rate of those who were intubated vs those not? What is the down time from arrest to CPR to ALS intervention? How does that compare to the out of hospital Urban environment i.e. the 17 story walk-up? In the Rural Environment your resposne time can be 30 min or more for ALS Care. what are the variables? In EMS no two system response models or communities are the same. The european system and response models are vastly diffrent than our own. The education and training may not be comparable and lastly most of the study being conducted are by really smart indivuals that may not have first hand knowledge or experience of out-of hospital medicine. Out of hospital medcine is too dynamic with soo many varibles in so many diffrent areas both clinical & non-clincical. Great article

  4. When I qualified here in the UK, we had to do 25 successful live intubations in a clinical setting (theatres). Now, new University Qualified Para’s have to do their practice tubes in the classroom, on mannequins. Then they get their numbers by practice in an on-the-job setting. This will always be under stress (collapsed patient) and not in a controlled environment such as a Hospital theatre, under supervision of a Consultant Anaethesist. We also had to go into theatres (OR’s) every year or two to refresh and maintain those skills, not any more.

    In addition, cannulation is now taught in the classroom on rubber arms, and the 25 “live” requirements are carried out under supervision of a Paramedic Mentor on the road. Again, this could be in a stressful situation (poorly or collapsed patient).

    Having to Mentor students and supervising their practicing reduces the opportunity for Qualified Paramedics to maintain their own practical skills. For that reason, I gave up my formal Mentoring role.

  5. The biggest problem I’ve seen with ET skill is technique. We are taught to use the sniffing position but most medics attempt intubation with the patient flat on the floor/stretcher. Put a folded towel under the patient’s head and intubation becomes a cake walk.

  6. The above comment is basically a rant about the route paramedics become qualified, an argument that will probably go on for a long time.

    Jerry, you are correct in that firstly as a paramedic via the university route we were taught skills such as intubation and cannulation on rubber arms and heads to assess we had the ability to carry out the skills required. However, we were then required to pass practical exams, assessed by a medical professional or we would not be allowed to take these skills outside of the university.

    We are sent to placements such as theatres, A&E and various other departments were we had to be assessed further (e.g by a consultant anaesthetists in theatres). The assessor would then have to sign a document stating that the student was able to carry out these skills to a required level. Admittedly these placements do include emergency ambulances.

    As for being in a controlled environment; how often are we required to perform these skills in the clinical environment as paramedics. Secondly what better place to learn such skills when the circumstances are not in your favour. Carrying out these skills in such situations can only make you better at it.

    Finally the idea of removing intubation from a paramedics skill base is just stupid. Maybe the people who come up with these results should spend time in the pre-hospital setting and try a intubation when its cold, wet and dark or when the family is screaming at you to do something instead of being in a nicely lit, warm A&E.

  7. Voitek Novakovski BSRC, RRT, NREMT-P, CCEMT-P

    I’ve been a Respiratory Therapist since 1974 and involved in EMS since 1982. RTs were trained to manage the airway and every hospital I went to had me veryfy my skills at codes throughout the hospital, and not in the controled environment of the OR, although I did a little of that too, but, I didn’t find that very valuable when it came to managing the airway during a code. Studies have verified the skill of an RT as equivalant to critical care, ER, and pulmonary physicians. So what is the difference? I see major differences in technique between RTs and my EMS collegues. I also see the amount of emphasis placed upon CORRECT ventilation technique both pre and post intubation.

    Let’s not use bad technique as a reason to not perform what is the standard of care in the hospital. Supraglotic airways do not protect against aspiration, nor do they work as well in the grosly obese. Those of us who work in the rural environment with long transport times need to “assure” a difinitive airway.

    What we need to do is spend more time teaching proper technique. Instead of competing with anesthesia folks for OR time, find a RT department where they routinely intubate and get the paramedics in with them. The experience they will get will be more like what they will find in practice. No, the patient will not be upside down in a car, but they might be in a bathroom, or on the floor in the visitors lounge or something like that. Good simulators work too, if you can afford them. The point is, every article I read points to improper technique in either intubation or ventilation. OK, so teach them proper technique!!!

  8. “Finally the idea of removing intubation from a paramedics skill base is just stupid. Maybe the people who come up with these results should spend time in the pre-hospital setting and try a intubation when its cold, wet and dark or when the family is screaming at you to do something instead of being in a nicely lit, warm A&E.”

    I believe that that is exactly the point. You can’t compare field intubation to operating theater intubation. That is certainly NOT an argument for keeping paramedic intubation. If the skill adds no survival benefit for the patient in the EMS setting and our success rates are not good, then why are we still doing it? If the ego boost of being able to intubate is held above the desire to improve patient outcomes, then we are misguided and lose our credibility as patient advocates.

  9. “we dont need to lower the bar and take intubation out of the paramedics training, what needs to be done is more training more strenuous training,more practical training.Here we have intubation training for paramedics where they must practice in many different positions one of which being the patient is up side down and must be intubated. When you have 20-30+ min ride times to the nearest hospitals intubation can be critical in helping to sustain life.

  10. Taking Intubation out of the field is not the answer. Improved training and skills management is. A problem I do see in the field is some not all do have the EGO that they absolutley have to get the tube. More and more emphasis should be focused on training not only the paramedic in the field but in the clinical setting to ensure the skill is maintained. But this shouldn’t be up to the medical director it should be up to the medic to be humble enough to ask for additional time. I haven’t used a hare traction in years. I try to at least find a way to get some in house training to brush up those skills since we hardly use them.

    As far as the clinicals taking place in back of the EMS rig. This is primarily where most paramedics work. Thusforth the stress anxiety and sense of urgency are present building your skills or precepting in this location suits you best. Some time should be spent in a controlled enviorment however Practice where you’ll work. It’ll make you a better medic when you have the experienced the real deal vs. OMG this isn’t what its like in the OR,ICU, or ER

    ETT and RSI are gonna be skills that are gonna be around and critisized in everyway. What suits the patients best always comes first.

  11. Sara Smith, your save pecentage is quite high. 40% eh? Ive been a medic for 12 years and know this is IMPOSSIBLE. You may want to check for a pulse and analyze before you commence chest compressions. 98% of your 20 codes still had pulses.

    And forget this truth anyway. Your post is the worst, most unintelligent post ive ever read on any ems site. This is not a site to brag about how good you are ( and I have the feling you are a very weak medic).

    In my 12 years and 100+ codes maybe 3 wlked out of hospital.

    Get real Sarah, quit living a lie, give Narcan before you run a code on a simple OD pt.

  12. I dont understand why CA is the basis for intubation studies. How is this the best bench mark of whether or not intubation is a success driven skill. We are taking patients who are already dead and deciding that if they live, intubation was apporopriate. What about all the other patients out there, resp arrest, traumas, unconcious, etc. who have been intubated. At the end of the day, intubation is still the only way to definitively control the airway. Although i believe the king has its place, intubation has and always should be a staple of prehospital care.

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