The new ERC 2025 recommendations for advanced airway management during CPR
Airway and ventilation
📌During CPR, start with basic airway techniques and progress stepwise according to the skills of the rescuer until effective ventilation is achieved.
📌Give the highest feasible inspired oxygen during CPR.
Start effective ventilation breaths as soon as possible ensuring the rate and tidal volume are appropriate to prevent both inadequate ventilation (hypoventilation) and excessive ventilation (hyperventilation).
📌Deliver effective bag-mask ventilation breaths by optimising mask seal and airway patency and if necessary, use a two-person technique for bag-mask ventilation.
📌Give each inspiratory breath over 1s to achieve a visible chest movement.
📌When using a supraglottic airway (SGA), an i-gel is preferred to a laryngeal tube.
📌Tracheal intubation should only be attempted by rescuers with a high success rate and with the use of continuous waveform capnography. The expert consensus is that a high tracheal intubation success rate is over 95 % within two attempts at intubation.
📌Aim for less than a 5-second interruption in chest compression for tracheal intubation.
📌Use direct or video laryngoscopy for tracheal intubation according to local protocols and rescuer experience. In settings where video laryngoscopy is immediately available, it is preferable to use video laryngoscopy instead of direct laryngoscopy.
📌A sustained ETCO trace on waveform capnography must be used to exclude oesophageal placement of the tracheal tube.
📌Once a tracheal tube or a SGA has been inserted, ventilate the lungs at a rate of 10 min-' and continue chest compressions without pausing during ventilations. With a SGA, if gas leakage results in inadequate ventilation, pause compressions for ventilation using a compression-ventilation ratio of 30:2.
📌If using mechanical ventilation, use a volume-controlled mode during chest compressions set the ventilator to a tidal volume of 6-8 mL kg-' (predicted body weight), or to achieve a visible chest movement, the maximum inspired oxygen, a respiratory rate of 10 min-', an inspiratory time of 1-2 s, a positive end expiratory pressure (PEEP) 0-5 cm H2O, the peak pressure alarm at :0-70 cm H20, and the flow trigger off. Ensure mechanical ventilation is effective and if not, use manual ventilation.
📌If standard airway management strategies (oropharyngeal airway and bag-mask/supraglottic airway/ tracheal tube) fail during cardiac arrest, appropriately trained rescuers should attempt surgical cricothyroidotomy to enable oxygenation and ventilation.