American Journal of Emergency Medicine (2010) 28, 499504

www.elsevier.com/locate/ajem

Brief Report

Verification of airway management during cardiac arrest: a

manikin-based observational study
Masanao Kobayashi MD a,, Akira Fujiwara MD a , Hiroshi Morita MD a ,
Yasuhisa Nishimoto MD a , Takayuki Mishima MD a , Masahiko Nitta MDa
,
Toshihiro Hotta MD a , Toshimasa Hayashi MD a , Yasuyuki Hayashi MD b , Kenji Sato EMT
c
a

Department of Emergency Medicine, Osaka Medical College Hospital, Takatsuki-city, Osaka 569-8686, Japan
Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita-city, Osaka, Japan
c
Kawanishi City Fire Bureau, Kawanishi-city Hyogo, Japan
b

Received 23 January 2009; revised 6 March 2009; accepted 6 March 2009

Abstract
Introduction: The study aimed to clarify the difficulties concerning insertion of advanced airway
devices during cardiac arrest.
Method: In an observational study using manikins, we examined the airway management techniques
of
19 teams at the Osaka Senri medical rally. For ex-post verification, we recorded chest compression
and ventilation using the Resusci Anne Advanced Skill Trainer (Laerdal, Norway) and recorded
actions of the teams using a video camera.
Results: Only a small proportion of teams did not adopt advanced airway management (4 teams,
21.1%). Thirteen teams selected tracheal intubation. None showed chest compression interruptions
during intubation manipulation, and the median duration of chest compression interruption during
confirmation of postintubation was 6.4 seconds. The median duration of ventilation interruption during
intubation was 45.5 seconds. When teams were evaluated for the duration of direct laryngoscopy, that
is, so-called duration of intubation, the median duration was 19 seconds, which constituted a large
underestimate compared with the duration of ventilation interruption. This represents an underestimation of about 27 seconds. We considered the issues to be identified for shortening the duration
of ventilation interruption.
Conclusion: From this study, it is clear that the strategy of Guideline 2005 that was designed to
minimize chest compression interruption has permeated deeply. The recommendation that the duration
of intubation manipulation should not exceed 30 seconds has had various interpretations, but it is
important to focus on the duration of ventilation interruption.
2010 Elsevier Inc. All rights reserved.

1. Introduction
Corresponding author. Tel.: +81 (0)726 83 1221; fax: +81 (0)726 84
6262.
E-mail address: emm003@poh.osaka-med.ac.jp (M. Kobayashi).
0735-6757/$ see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2009.03.006

Insertion of advanced airway devices, including tracheal

intubation, is a routine procedure, but currently, there is no
scientific evidence that the rate of hospital discharge in
cardiac arrest patients has been improved by this means.

244

M. Kobayashi et al.

There are various possible reasons for why the

effectiveness of advanced airway devices cannot be
demonstrated. For example, the duration of chest
compression interruption or that of ventilation interruption
during device insertion may be unacceptably long.
Therefore, it is important to investigate the negative
influences of advanced airway device insertion on
cardiopulmonary resuscitation. For this reason, we verified
the activities of rescuers and clarified problems concerning
the insertion of advanced airway devices, including
tracheal intubation, at a medical rally.

2. Methods
In the Osaka Senri medical rally, a 6-member team
performed a 10-minute competitive exercise at each station
[1]. The competing teams consisted of doctors and nurses
working at emergency medical care centers and their local
emergency medical technicians (EMTs). The 19 teams who
participated in the 7th Osaka Senri Medical Rally (2008)
were evaluated objectively in the present observational
study. Competition teams were selected by lot from
applicants from all over Japan. The applicants were
required to give consent for participation in the study. In
addition, we obtained the contestant's consent for
publication about the study after the competition.
A Resusci Anne Advanced Skill Trainer (Laerdal
foundation, Stavanger, Norway) was used. Data on chest
compression and ventilation obtained from this simulator
were stored into a personal computer, and images of the
competitors' actions were recorded with a digital video
camera for ex-post verification.
The following scenario was used. When a starting
emergency rescue team arrives at the scene after an

Fig. 1

emergency request, a bystander from the general public is

providing cardiopulmonary resuscitation. Although defibrillating shock has already been administered 3 times
using an automated external defibrillator, ventricular
fibrillation is still continuing. It is assumed that the starting
emergency rescue team consists of 2 EMTs and 1 nurse.
They are allowed to use various airway management
devices, including tracheal intubation, and to administer
adrenalin intravenously. The starting emergency rescue
team requests a doctor-car team, consisting of 2 doctors and
1 nurse. Each competitor is allowed to select any airway
management technique.
The scenario presented no serious problems regarding
airway and breathing conditions, and bag-mask ventilation
could be provided normally. However, it was assumed that
if direct laryngoscopy was conducted, it would not be
possible to observe the glottis due to copious secretions.
The person in charge of reporting the situation (the socalled voice of God) described the situation orally: the
glottis cannot be seen because of copious secretion when
direct laryngoscopy is conducted to perform tracheal
intubation. If the competitor's accurate suction technique
was confirmed, which was, after switching on a portable
suction device, connecting a sucker, and inserting the tip of
the sucker into the area close to the larynx under the
circumstances of direct laryngoscopy, the person in charge
of reporting the situation would utter sounds imitating
suction and announce that the glottis had become visible. It
was assumed that if suction was conducted once, the glottis
could be confirmed during direct laryngoscopy after the
second attempt.
Numbers derived from the video images and the
simulator are represented as median values and interquartile ranges. SPSS II Version 11.0J (SPSS Inc, Chicago,
Ill) was used for statistical analysis. The Mann-Whitney U
test was used for comparisons between 2 unpaired groups

Time needed for insertion of advanced airway devices.

and the Wilcoxon signed rank test for comparisons

between 2 paired groups. The criterion for a significant
difference was P b .05.
Time required for tracheal intubation was defined as
follows (Fig. 1): (a) before direct laryngoscopytime
between the final ventilation and the initiation of insertion
of a laryngoscope; (b) durations of direct laryngoscopy, that
is, the so called duration of intubationtime between
the start of insertion of a laryngoscope and removal of
the laryngoscope after completion of secretion aspiration
and/or intubation; and (c) after direct laryngoscopytime
between removal of a laryngoscope and restarting
ventilation. The sum a + b + c was the duration of
ventilation interruption.

3. Results
Fifteen teams selected insertion of advanced airway
devices (Table 1). Two teams selected laryngeal tube (LT),
one of which achieved their goal by using the first insertion
technique. The other ran out of competition time before
attempting insertion. Among the 13 teams selecting tracheal
intubation, teams 3, 12, and 13 completed intubation during
the first direct laryngoscopy. In other words, they
performed intubation by a series of actions following
suction. The remaining nine teams (nos. 1, 2, 4, 6, and 711) aspirated secretions around the larynx during the first
direct laryngo- scopy, and returned to bag-mask
ventilation, completing intubation during the second
direct laryngoscopy. Team 5

Table 1

could not conduct intubation during the second direct

laryngoscopy but were able to complete it during the third
direct laryngoscopy. Four teams performed resuscitation
without insertion of advanced airway devices and with
basic airway management alone. However, no teams
selected the Combitube (Tyco-Kendall, Mansfield, MA),
laryngeal mask airway, oropharyngeal airway, or
nasopharyngeal airway.
Only 3 (nos. 1-3) of 13 teams implemented direct
laryngoscopy after preparing for suction. Because 2 (nos. 1
and 2) of these 3 teams promptly returned to bag-mask
ventilation after aspiration, the durations of ventilation
interruption in the 2 teams were 19 and 29 seconds,
respectively, which were short.
On the other hand, 10 teams (nos. 4-13) performing
direct laryngoscopy without preparing for aspiration
during tracheal intubation encountered a situation in
which the glottis could not be confirmed because
secretions were present, and they started preparations for
aspiration for the first time and abandoned ventilation and
continued direct laryngoscopy until preparations for suction
were completed. Because 2 (teams 4 and 5) of these 10
teams could perform suction relatively early and returned to
bag-mask ventilation, the durations of ventilation
interruption in the 2 teams were
31 and 24 seconds, respectively, which were short.
However,
2 teams (nos. 6 and 7) who took the time to prepare for
suction had ventilation interruptions of 73 and 62 seconds,
respectively, until they returned to bag-mask ventilation
after suction. Two teams (nos. 14 and 15) selecting LT and
4 teams accomplishing resuscitation with bag-mask
ventilation had no particular problems with airway
management.

List of teams that selected insertion of advanced airway devices

No. Device Occupation who Preparing for

Returning to bagmanaged airway aspiration at direct mask ventilation
laryngoscopy
after aspiration
immediately

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
ETT
LT
LT

EMT
Doctor
EMT
EMT
Doctor
Doctor
EMT
Doctor
EMT
Doctor
Doctor
EMT
EMT
EMT
EMT

+
+
+

*
*

+
+

+
+
+
+

*
*

AED, automated external defibrillator; ETT, endotracheal tube.

* No data.

Use of AED
coincided with
the timing of
defibrillating
shock
+

+
+
+
+
+
+

Duration of
ventilation
interruption/duration
of so-called device
insertion (s)
First

Second Third

19/7
29/16
194/39
31/14
24/21
73/8
62/24
59/48
83/59
97/58
80/67
91/73
96/64
31/15
*

87/23 *
34/20 *
*
*
30/10 *
56/50 23/11
41/13 *
62/18 *
120/28 *
50/17 *
30/20 *
76/32 *
*
*
*
*
*
*
*
*

Duration of chest
compression
interruption during
confirmation of
inserted device (s)
8.1
3.7
10.9
11.3
0
6.3
9.8
3.2
4.5
*
0
11.8
6.4
7.1
*

Fig. 2

Durations of chest compression interruption during confirmation of ventilation after tracheal intubation.

Next, we examined chest compression interruption

associated with intubation manipulation. Of the 13 teams
that selected tracheal intubation, none showed chest
compression interruptions during intubation manipulation.
Of these, one ran out of time and we could not confirm
ventilation after device insertion. Therefore, we studied
the duration of chest compression interruption during
confirmation of postintubation ventilation in 12 teams
(Fig. 2). None showed chest compression interruptions
during intubation manipulation. The median duration of
chest compression interruption during confirmation of

Fig. 3

postintubation ventilation was 6.4 seconds. Duration of

more than 10 seconds was observed in 3 teams (25%).
The duration of chest compression interruption by the
doctors was significantly shorter compared to the EMTs
(P = .007).
We also studied the duration of ventilation interruption
and that of direct laryngoscopy during tracheal intubation
(Fig. 3). In this study, we excluded 3 cases in which both
aspiration and intubation manipulation were performed in a
series; we analyzed data only on the duration of intubation
manipulation purely. The median duration of ventilation

Durations of ventilation interruption and direct laryngoscopy during tracheal intubation.

interruption was 45.5 seconds, and only 3 teams (30%)

were able to limit the duration of ventilation
interruption to
30 seconds or less. On the other hand, evaluation using the
duration of direct laryngoscopy showed that these 10 teams
had a median of 19 seconds, which was significantly
shorter (P = .005) than the duration of ventilation
interruption as an
index;
this
represents
an
underestimation of about
27 seconds.

4. Discussion
From this study, it is clear that the strategy of Guideline
2005 that was designed to minimize chest compression
interruption has permeated deeply. As a result of emphasis
on venous return and cardiac output, the number of
ventilations and tidal volume is obviously moving toward
hypoventilation. The priority of the ventilation become
surely low, but its degree has not been clarified and is still
controversial. Conversely, the importance of performing
each ventilation securely is increasing. Therefore, the
duration of ventilation interruption requires closer attention
than previously thought necessary. Persons conducting
resuscitation on a routine basis at least should not
underestimate ventilation. We want to warn against any
tendency to underestimating ventilation. Of course, it is
necessary to perform ventilation properly on having
performed chest compression surely.
The so-called 30-second rule for intubation, that is, that
intubation manipulation should be performed within 30
seconds, is widely recognized by healthcare professionals.
Specifically, the European Resuscitation Council Advanced
Life Support course manual says that, No intubation
attempt should take longer than 30 sec [2], and the
American Heart Association Advanced Cardiovascular Life
Support Provider Manual states that, If a laryngoscope
and tube are not readily available or if the intubation
attempt is not successful within 30 seconds, return to bagmask ventilation [3]. However, no manual provides
clear definitions of intubation attempts, so there are no
clear answers to the questions of when an intubation
attempt begins and ends (eg, whether it starts from the final
ventilation, opening the patient's mouth, or insertion of a
laryngoscope; or whether it ends with the passage of a
tracheal tube through the glottis, the completion of cuff
inflation, or the restarting of ventilation).
On the other hand, there are strict stipulations that the
duration of ventilation interruption should be no longer
than 30 seconds: Barbara Aehlert states in the Advanced
Cardiovascular Life Support study guide, Do not exceed
30 seconds from ventilation to ventilation for each
intubation attempt [4]. American Heart Association
Guidelines 2000 states During the process of tracheal
intubation, the maximum interruption to ventilation should
be 30 seconds [5].

We found that even if the duration of direct laryngoscopy could be limited to 30 seconds or less, it was
greatly exceeded by the actual duration of ventilation
interruption. The difference has not been discussed
frequently, and we demonstrated that the difference was
larger than the expected value. Considering the original
purpose to set this rule, the duration should be for
ventilation interruption, not for device insertion. If this is
not understood, unacceptable events might occur in
medical practice. If the duration of direct laryngoscopy
was limited to 30 seconds or less, direct laryngoscopy
should be performed after preparation for suction, and if
viewing the glottis is likely to take time, mask ventilation
should be performed promptly.
To shorten the duration of ventilation interruption, it is
important to make certain preparations for tracheal intubation, such as considering stylets and shapes of the tracheal
tube and lubricant agents, and to place a pillow beneath the
head of the patient beforehand to ensure a sniffing position,
in addition to the above-mentioned preparation for suction
during the period between the final ventilation and direct
laryngoscopy. In addition, it is important to shift to
intubation manipulation immediately after performing
venti- lation twice.

5. Limitations
The present study cannot show how the duration of
ventilation interruption associated with the insertion of an
advanced airway device influences the prognosis of a
patient. It is possible that the abnormal stress associated
with competition led to results different from those that
would be obtained in daily clinical practice.

6. Conclusions
The duration of ventilation interruption associated with
the insertion of advanced airway devices was considerably
longer than expected. It is important to focus on the
duration of ventilation interruption. Although it may be
difficult to perform tracheal intubation with 30 seconds or
less duration of ventilation interruption, the basic points of
tracheal intubation should be emphasized.

Acknowledgments
We thank the organizers of the Osaka Senri medical
rally; the volunteer participants who took part in station
management; the manufacturers who lent us medical
equipment; the competing teams who took part in the
study; and Dr Yoshio Horikawa (Department of
Anesthesia,

Nishi-Kobe Medical Center) and Dr Seiji Miyahara

(Department of Anesthesia, Kanzaki Municipal General
Hospital), who have provided valuable suggestions.

References
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observational study on cardiopulmonary resuscitation skills at the
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[2] European Resuscitation Council. Airway management and ventilation.
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et al, editors. Advanced life support course manual. 5th ed. Antwerp

(Belgium): European Resuscitation Council; 2006. p. 41-55.

[Chapter 6].
[3] American Heart Association. ACLS_supplementary (PDF file in
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2000;102:I95-I104.

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