To Intubate or Not Intubate During In-Hospital Codes?

The 2015 American Heart Association Advanced Cardiovascular Life Support guidelines deemphasizes advanced airway placement during the initial resuscitation. Out-of-hospital–arrest data suggest lower survival among patients who are intubated in the field.  Therefore, it is important to determine the importance of advanced airway placement during in-hospital cardiac arrests.  To determine whether this applies to inpatients, investigators examined resuscitations of more than 108,000 patients in a U.S. registry via a time-matched propensity analysis.

Seventy percent of patients were intubated during their code events.  The vast majority of these intubations occurred within 15 minutes of CPR onset. Patients with an initial non-shockable rhythms (i.e., pulseless electrical activity [PEA] or asystole) were more likely to be intubated than were those with ventricular fibrillation or ventricular tachycardia (69% vs. 53%).

This observational study noted that patients who were intubated during resuscitation were significantly less likely to survive to discharge than those who were not (16% vs. 19%).  In addition, those patients who were intubated were less likely to be discharged with a good functional status compared with those who were not intubated (11% vs. 14%).  The most pronounced difference were seen in patients who had an initial shockable rhythm (VF or pulseless VT).

This observational study raises important questions about our tendency as hospital or emergency physicians to place an advanced airway if ROSC is not obtained after the first few rounds of CPR.  Attempts at intubation can interrupt chest compressions or slow defibrillation efforts.  We certainly need more data before a firm recommendation can be made, but I think this study at least points to the importance of NOT INTERRUPTING CHEST COMPRESSIONS during efforts to place an advanced airway.


  1. Andersen LW et al. Association between tracheal intubation during adult in-hospital cardiac arrest and survival. JAMA.  2017 Feb 7; 317:494. 
  2. Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data.JAMA.  2017 Feb 7; 317:477. 
Read all articles in Cardiovascular diseases, Emergency Procedures, Gastrointestinal diseases, Medical General, medical procedures, Respiratory diseases
Tags: advanced airway, asystole, cardiac arrest, CPR, HPC updates, intubation, PEA, pulseless electrical activity, ROSC, ventricular fibrillation, ventricular tachycardia

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