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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S559 Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC 1 C-EO 4. Emergency medical services systems that perform prehospital intubation in adults with cardiac arrest should provide a program of ongoing quality improvement to minimize complications and track overall supraglottic airway and endotracheal tube placement success rates. 2a B-R 5. If an advanced airway is used for adults with OHCA, a supraglottic airway can be acceptable in settings with low endotracheal intubation success rate or minimal training opportunities. 2a B-R 6. If an advanced airway is used, either a supraglottic airway or endotracheal tube can be used for adults with OHCA in settings with high endotracheal intubation success rates or optimal training opportunities for endotracheal tube placement. 2a B-NR 7. If an advanced airway is used for adults in cardiac arrest in the in-hospital setting by expert health care professionals trained in these procedures, either a supraglottic airway or endotracheal tube can be used. 2b B-R 8. Either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting depending on the situation and skill set of the professional. 2b C-LD 9. If an advanced airway is in place, it may be reasonable for the clinician to deliver 1 breath every 6 s (10 breaths/min) while continuous chest compressions are being performed. Synopsis Airway management during cardiac arrest usually commences with a basic strategy such as BMV. In addition, it may be helpful for professionals to become proficient in one advanced airway strategy—endotracheal intubation (ETI) or supraglottic airway (SGA) insertion—as well as a second (backup) strategy for use if they are unable to establish the first-choice airway adjunct. Because placement of an advanced airway may result in interruption of chest compressions, a malpositioned device, or hyperventilation, professionals need weigh these risks against potential benefits. The 2019 focused update on use of advanced airways and Part 3: Adult Basic and Advanced Life Support from the 2020 Guidelines addressed the use of advanced airways in cardiac arrest. The 2020 Guidelines state that BMV or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1,2 A key aspect of airway management decision-making is the health care professional’s airway management skill and experience, frequent retraining and ongoing quality improvement to minimize airway management complications. Thus, the ultimate decision of the use, type, and timing of an advanced airway will require consideration of a host of patient and professional characteristics that are not easily defined in a global recommendation (Figure 5). Recommendation-Specific Supportive Text 1 Frequent retraining is important to maintain a health care professional’s psychomotor airway management skills.3,4 The manner in which this training is best accomplished is unclear. Research is necessary to address the specific type, amount, and frequency of training experiences that optimize airway management performance during cardiac arrest. 2. Although an advanced airway can be placed without interrupting chest compressions,5 interruptions frequently occur. Therefore, health care professionals should weigh the potential benefits of an advanced airway with the benefits of maintaining a high chest compression fraction.6–8 This is particularly true in cardiac arrest patients with shockable rhythms where CPR and defibrillation must take priority due to the strong association of early CPR and defibrillation with enhanced survival with favorable neurological outcome. In contrast, in arrests with non-shockable rhythms, early airway management is possible in resuscitations where CPR performance and epinephrine administration have already been optimized. 3. In a small clinical trial and several observational studies, waveform capnography was 100% specific for confirming endotracheal tube position during cardiac arrest.9–11 The sensitivity of waveform capnography decreases after a prolonged cardiac arrest.9–11 The use of waveform capnography to assess the placement of other advanced airways (eg, Combitube, laryngeal mask airway) has not been studied. 4. The writing group acknowledges the critical roles of tracking the overall success rate for systems performing ETI. This data will allow systems to make informed decisions as to whether practice should allow for ETI, move toward SGA, or simply use BMV for patients in cardiac arrest; recommendations will vary depending on the overall success rate in a given system. There is a clear need for further research with both patient- and professional- centered outcomes to assess the impact of prehospital quality improvement on selecting and maintaining the most appropriate airway management approach for EMS professionals within an agency. 5 and 6. One RCT of OHCA comparing SGA (iGel) to ETI in a non–physician-based EMS system (ETI success, 69%) found no difference in survival or survival with favorable neurologic outcome at hospital discharge.12 A second RCT of OHCA comparing SGA (laryngeal tube) to ETI in a non– physician-based EMS system (ETI success, Recommendations for Advanced Airway Placement During Resuscitation (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026