CPR with rescue breathing associated with improved OHCA outcomes in children

Although cardiopulmonary resuscitation only (CO-CPR) is the most commonly performed type of CPR, emergency CPR (RB-CPR) is associated with better outcomes in pediatric out-of-hospital cardiac arrest. This is evident from research published in the Journal of the American College of Cardiology. 1

Less than 10% of children survive cardiac arrest outside of the hospital, but onlookers CPR are generally associated with better survival rates. CO-CPR appears to be as effective as resuscitation CPR RB-CPR in adults, but may be less effective in children who typically experience cardiac arrest out of hospital due to asphyxia.

Although efforts have been made to teach CO-CPR and improve viewer CPR rates – resulting in increased out-of-hospital survival rates in adults – the impact of these efforts on the pediatric population is unknown.

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The researchers therefore analyzed data from the Cardiac Arrest Registry to Enhance Survival (CARES) registry to test the hypothesis that RB-CPR is associated with neurologically favorable survival compared to CO-CPR in pediatric patients.

The CARES registry covers a catchment area of ​​145 million people in 28 US states. Cardiac arrests are recorded by community-level 911 centers and contain information about cerebral performance.

The current study included pediatric out-of-hospital non-traumatic cardiac arrest submitted to the CARES registry between 2013 and 2019 – defined as apnea and unresponsiveness that resulted in either CPR or defibrillation resuscitation attempts. Children with obvious signs of death or non-resuscitation orders were excluded.

Investigators received data on age, gender, race and ethnicity, witness status, location of arrest, starting rhythm, use of the automated external defibrillator (AED), and region of arrest. The primary study outcome was neurologically favorable survival, defined as a cerebral performance category score of 1 or 2 – no or moderate disability – at the time of discharge from hospital. Neurologically unfavorable survival was defined as cerebral performance category 3 or 4 – severe disability or coma / vegetative state.

A total of 13,060 pediatric cardiac arrests were identified in the CARES database, of which 46.5% received bystander CPR. After applying exclusions, 10,429 cardiac arrests were evaluated. Within this group, 55.6% received CO-CPR and 45.3% received RB-CPR. The presumed etiology of arrest was respiratory arrest, drowning, drug overdose, electric shock, and bleeding in 44.4%, 32.8%, 8.8%, 1.8%, 0.2%, and 0.2% of cases, respectively .

Cardiac arrest was more common in infants, boys, and both black and white children. The majority took place in a home or dormitory with no shocking rhythm and no AED deployment prior to the arrival of the emergency services.

Over the 6-year study period, the rates of onlookers’ CPR did not change. Bystander CPR was most commonly performed by a lay family member, lay person, or lay person with medical training (71.7%, 21.9% and 6.4%, respectively). However, a significant increase in the proportion of pediatric cardiac arrests receiving CO-CPR was noted by the researchers.

Family members and laypeople were more likely to perform CO-CPR (54.8% and 58.9%, respectively), while laypeople with medical training were more likely to perform RB-CPR (61.5%).

Researchers found that 8.6% of cardiac arrests resulted in neurologically favorable outcomes. This rate has not changed during the study period. In analyzes that were not adjusted for demographic and clinical characteristics, arrests with RB- or CO-CPR had better results than without CPR (13.4% and 12.2% vs. 5.8%).

The results of a multivariate analysis showed that RB-CPR and CO-CPR were both independently associated with neurologically favorable survival compared to no CPR (adjusted odds ratios [aORs] for RB-CPR and CO-CPR 2.16 and 1.61). In a separate model that excluded those who did not receive CPR, the researchers found that RB-CPR was associated with higher chances of neurologically favorable survival compared to CO-CPR (aOR, 1.36).

According to age group, neurologically favorable survival was most common in adolescents (16.5% vs. 10.6% of children and 4.6% of infants). In infants and children, RB-CPR was more frequently associated with neurologically favorable survival (6.9% vs. 5.2% and 17.3% vs. 13.9%). In adolescents, the data were similar, showing neurologically favorable survival in 25.7% of those who received RB-CPR versus 23.7% who received CO-CPR.

Limitations of the study include the observational nature of the data, the lack of some type of CPR by bystander in all arrests, and lack of information about dispatcher instructions, quality of CPR, or training of lay rescuers, and possible post-cardiac arrest in hospital disturbances.

“These results”, concluded the study authors, “support the present” [American Heart Association] Guidelines with RB-CPR as the preferred modality for pediatrics [out-of-hospital cardiac arrest]. “

In an editorial comment, Gene Yong-Kwang Ong, MBBS, of the Emergency Medicine Department at KK Women’s and Children’s Hospital in Singapore and Duke-NUS Medical School in Singapore noted that this study was “critical to the limited published pediatric data.” on the subject “2 with many important observations. The study’s results have important implications, especially in light of the COVID-19 pandemic.

“The perceived reluctance to ventilate adult victims of cardiac arrest was partly due to hygiene and health concerns [the] Risk of infection, ”he wrote. “These considerations in providing life-saving care for a young family member may not be exactly the same for adult victims of cardiac arrest. Even during the ongoing COVID-19 pandemic, there is a risk that emergency services will get through COVID-19 [the] The provision of rescue ventilation is more acceptable compared to adults, as the victims of pediatric cardiac arrest are likely to be family members. “


  1. MY Naim, HM Griffis, RA Berg et al. Cardiopulmonary resuscitation with exclusive compression compared to ventilatory cardiopulmonary resuscitation after outpatient cardiac arrest. J. Am. Coll. Cardiol. Published online August 30, 2021. doi: 10.1016 / j.jacc.2021.06.042
  2. Ong GY-K. Cardiopulmonary resuscitation only with chest compression in pediatric out-of-hospital cardiac arrest: (not) takes my breath away. J. Am. Coll. Cardiol. Published online August 30, 2021. doi: 10.1016 / j.jacc.2021.07.029

This article originally appeared on The Cardiology Advisor

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