The introduction of the 2000 Guidelines for
Cardiopulmonary Resuscitation emphasizes a new, evidence-based approach to the science of ventilation during
cardiopulmonary resuscitation (
CPR). New laboratory and clinical science underemphasizes the role of ventilation immediately after a dysrhythmic
cardiac arrest (arrest primarily resulting from a cardiovascular event, such as ventricular defibrillation or
asystole). However, the classic airway patency, breathing, and circulation (ABC)
CPR sequence remains a fundamental factor for the immediate survival and neurologic outcome of patients after asphyxial
cardiac arrest (
cardiac arrest primarily resulting from respiratory arrest). The hidden danger of ventilation of the unprotected airway during
cardiac arrest either by mouth-to-mouth or by mask can be minimized by applying ventilation techniques that decrease stomach gas insufflation. This goal can be achieved by decreasing peak inspiratory flow rate, increasing inspiratory time, and decreasing tidal volume to approximately 5 to 7 mL/kg, if
oxygen is available. Laboratory and clinical evidence recently supported the important role of alternative airway devices to mask ventilation and endotracheal intubation in the chain of survival. In particular, the laryngeal mask airway and esophageal Combitube proved to be effective alternatives in providing oxygenation and ventilation to the patient in
cardiac arrest in the prehospital arena in North America. Prompt recognition of supraglottic obstruction of the airway is fundamental for the management of patients in
cardiac arrest when ventilation and oxygenation cannot be provided by conventional methods. "Minimally invasive" cricothyroidotomy devices are now available for the professional health care provider who is not proficient or comfortable with performing an emergency surgical
tracheotomy or cricothyroidotomy. Finally, a recent device that affects the relative influence of
positive pressure ventilation on the hemodynamics during
cardiac arrest has been introduced, the inspiratory impedance threshold valve, with the goal of maximizing coronary and cerebral perfusion while performing
CPR. Although the role of this alternative ventilatory methodology in
CPR is rapidly being established, we cannot overemphasize the need for proper training to minimize complications and maximize the efficacy of these new devices.