Advanced cardiac life support (ACLS) defines a process whereby patients with cardiopulmonary arrest can be resuscitated and sustained until admitted to an intensive care unit. The key requirements are restoration of cardiac output using chest compressions followed by restoration of heartbeat and heart rhythm, and ventilation of the lungs. 

Endotracheal intubation has long been recognised as the most effective means of artificial ventilation, both in the immediate and extended forms of assisted breathing. Although instruction in endotracheal intubation is included in ACLS courses, the only professional group that routinely performs this skill is anaesthetists. Other medical and nursing specialists have very few opportunities to practise this skill and virtually none outside a cardiac arrest situation. In large acute hospitals cardiac arrest teams would include an anaesthetist but in smaller hospitals, particularly those that do not perform emergency surgery, there may not be resident anaesthetic cover.

Over the years, many of the interventions included in ACLS such as central line insertion, calcium, sodium bicarbonate and intra-cardiac adrenaline have been abandoned as research has clarified those that are associated with improved outcomes – namely good quality chest compressions and early defibrillation when the rhythm is ventricular fibrillation or ventricular tachycardia. A recent BMJ Editorial¹ raised the question why then are we still intubating patients’ tracheas as part of their management during cardiopulmonary resuscitation.

It points out that the benefits of intubation during general anaesthesia are well known: effective ventilation in patients with poor pulmonary compliance, delivery of a high inspired oxygen concentration, the minimisation of gastric inflation, and protection against aspiration of gastric contents. During resuscitation, tracheal intubation allows ventilation to be continued without interrupting chest compressions. However, tracheal intubation also carries risks: multiple attempts, displacement of the tube, and unrecognised oesophageal intubation are relatively common, particularly in patients with out-of-hospital cardiac arrest (OHCA), where they have been reported to happen in up to 17% of patients. Furthermore, intubation can cause prolonged interruption to chest compressions, which is associated with a poorer outcome. Skill retention is another problem; paramedics in the UK perform an average of only one to four intubations a year each, and apart from anaesthetists and intensivists, hospital doctors perform virtually none.

The practical solution for cardiac arrest teams that do not have anaesthetists is to emphasise uninterrupted chest compression and immediate defibrillation with ventilation using a laryngeal airway rather than intubation.