Advanced airway interventions in paediatric cardiac arrest: Time to change the paradigm?

  • Eric J. Lavonas
    Correspondence
    Address: Department of Emergency Medicine, Denver Health, Denver, CO, USA.
    Affiliations
    Department of Emergency Medicine, Denver Health, Denver, CO, USA
    Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
    777 Bannock St, MC 0108, Denver, CO 80204, USA
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      The paradigm of Airway-Breathing-Circulation (ABC) in cardiopulmonary resuscitation (CPR) is at least 60 years old.

      Safar P, Brown TC, Holtey WJ, Wilder R. Ventilation and Circulation with Closed-Chest Cardiac Massage in Man. JAMA 1961; 176(7):574-6. https://doi.org/10.1001/jama.1961.03040200010003.

      Although rearranged to Circulation-Airway-Breathing (CAB) by the International Liaison Committee on Resuscitation (ILCOR) and other organizations in 2010, the paradigm that cardiac arrest resuscitation entails establishing and maintaining an open airway is as old as CPR itself. For adult advanced life support (ALS) providers, the paradigm has long been that tracheal intubation (TI) represents the definitive technique for airway management, contingent only on the ability of the resuscitation provider to intubate successfully.
      • Anonymous
      Part 6: Advanced Cardiovascular Life Support: Section 3: Adjuncts for Oxygenation, Ventilation, and Airway Control.

      Anonymous. Part 10: Pediatric Advanced Life Support. Resuscitation 2000;46: 343-399. https://doi.org/10.1016/S0300-9572(00)00296-3.

      Despite softening of these recommendations by the ILCOR in 2015,

      Callaway CW, Soar J, Aibiki M, et al. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2015;132: S84-S145. https://doi.org/10.1161/CIR.0000000000000273.

      reaffirmed in 2019 after publication of the CAAM trial,
      • Jabre P.
      • Penaloza A.
      • Pinero D.
      • et al.
      Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial.
      • Soar J.
      • Maconochie I.
      • Wyckoff M.H.
      • et al.
      2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
      advanced airway management remains the norm in adult cardiac arrest managed in highly developed countries. Recent published data from high quality registries in the United States (US) show that TI is successfully performed in 52% of out-of-hospital cardiac arrest (OCHA; 2011),
      • McMullan J.
      • Gerecht R.
      • Bonomo J.
      • et al.
      Airway management and out-of-hospital cardiac arrest outcome in the CARES registry.
      and 66% of in-hospital cardiac arrest (ICHA; 2000 – 2014)
      • Andersen L.W.
      • Granfeldt A.
      • Callaway C.W.
      • et al.
      Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.
      adult resuscitations.
      Paediatric cardiac arrest resuscitation differs from adult resuscitation in many important ways, with nuances that are often under-appreciated. Respiratory causes, including asphyxiation, drowning, and drug poisoning are more common than cardiac etiologies of OHCA.
      • Atkins D.L.
      • Everson-Stewart S.
      • Sears G.K.
      • et al.
      Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children: The Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.
      • Meyer L.
      • Stubbs B.
      • Fahrenbruch C.
      • et al.
      Incidence, Causes, and Survival Trends From Cardiovascular-Related Sudden Cardiac Arrest in Children and Young Adults 0 to 35 Years of Age: A 30-Year Review.
      At the cellular level, the pathophysiology of cardiac arrest preceded by a period of hypoxemia and hypercarbia is fundamentally different from sudden cardiac arrest,
      • Dezfulian C.
      • Orkin A.M.
      • Maron B.A.
      • et al.
      Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association.
      and outcomes from cardiac arrest of non-cardiac etiology are very poor compared with primary cardiac events.
      • Meyer L.
      • Stubbs B.
      • Fahrenbruch C.
      • et al.
      Incidence, Causes, and Survival Trends From Cardiovascular-Related Sudden Cardiac Arrest in Children and Young Adults 0 to 35 Years of Age: A 30-Year Review.
      Anatomic differences between the adult and paediatric airway, combined with the relative infrequency with which paramedics intubate infants and children, may lead to difficulty completing the procedure quickly and accurately. Unfortunately, three large, recent, high-quality paediatric registry studies could not measure the proportion of patients with failed intubation attempts.
      • Andersen L.W.
      • Raymond T.T.
      • Berg R.A.
      • et al.
      Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival.
      • Hansen M.L.
      • Lin A.
      • Eriksson C.
      • et al.
      A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database.
      • Ohashi-Fukuda N.
      • Fukuda T.
      • Doi K.
      • Morimura N.
      Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest.
      • Lavonas E.J.
      • Ohshimo S.
      • Nation K.
      • et al.
      Advanced airway interventions for paediatric cardiac arrest: A systematic review and meta-analysis.
      Intubation attempts are often associated with long interruptions in CPR,
      • Wang H.E.
      • Simeone S.J.
      • Weaver M.D.
      • Callaway C.W.
      Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.
      and advanced airway management may facilitate harmful hyperventilation.
      • Vogt L.
      • Sellmann T.
      • Wetzchewald D.
      • et al.
      Effects of Bag Mask Ventilation and Advanced Airway Management on Adherence to Ventilation Recommendations and Chest Compression Fraction: A Prospective Randomized Simulator-Based Trial.
      Advanced airway programs also require significant resources for training, skills maintenance, and quality assurance.
      In this issue of Resuscitation, Le Bastard and colleagues performed a technically sophisticated analysis of 1,579 paediatric resuscitations in the French National OHCA Registry (RéAC).

      Le Bastard Q, Rouzioux J, Montassier E, et al. Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study. Resuscitation 2021;168:191–198. https://doi.org/10.1016/j.resuscitation.2021.08.015.

      Using inverse probability of treatment weighting (IPTW) to control for potential confounding factors and after adjusting for age, gender, witnessed arrest, no-flow time, bystander CPR, first response team arrival time, traumatic etiology of arrest, and initial shockable rhythm, the authors found that children managed with TI had no better odds of return of spontaneous circulation (ROSC), compared to those managed without TI (paOR, 1.15; 95% CI, 0.80–1.65; P = 0.46), but had worse odds of survival with favorable neurologic outcome (paOR, 0.32; 95% CI, 0.19–0.54; P < 0.001). The comparison group in this study were children whose airway was managed by bag-mask ventilation (BMV) (93%) or supraglottic airway (7%).
      This work builds upon and reaffirms other propensity-matched observational studies by Hansen and Osashi-Fukuda in OHCA,
      • Hansen M.L.
      • Lin A.
      • Eriksson C.
      • et al.
      A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database.
      • Ohashi-Fukuda N.
      • Fukuda T.
      • Doi K.
      • Morimura N.
      Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest.
      and by Andersen in IHCA
      • Andersen L.W.
      • Raymond T.T.
      • Berg R.A.
      • et al.
      Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival.
      which form similar conclusions. Combining these four studies using a random-effects meta-analysis, the best estimate is that, for every 1000 resuscitations, 50 fewer children (95% Confidence Interval: 30 to 70 fewer) will survive with good neurologic function if intubation is performed prior to ROSC (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Random Effects Meta-Analysis of One Clinical Trial and Four Matched Cohort Studies of Tracheal Intubation in Pediatric Cardiac Arrest.
      Even the most sophisticated observational studies are susceptible to unmeasured bias. However, there are high quality clinical trial data on the subject. From 1994 to 1996, all children in Los Angeles, California requiring advanced airway interventions for OHCA were pseudorandomized, using an odd / even day scheme, to management with TI or BMV.

      Gausche M, Lewis RJ, Stratton SJ et al. Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study. JAMA 2000;283:783-90. https://doi.org/10.1001/jama.283.6.783.

      The majority of these children received airway management due to “cardiopulmonary arrest,” and outcomes for this subgroup are reported in Table 3 of the manuscript. While the overall outcomes were poor by contemporary standards, the trial found no effect of TI on either survival to hospital discharge (TI 8.0%, BMV 8.3%; OR 0.96; 95% CI: 0.53 – 1.73) or survival with good neurologic function (TI: 5.0%, BMV: 2.6%; OR 1.47; 95% CI: 0.65 – 3.32). However, despite a massive logistical effort to conduct the trial, the relatively small size (591 children in cardiac arrest with evaluable outcomes) leaves open the possibility of an important benefit, or harm, from TI. This is particularly true considering that outcomes, and probably optimal management, are not the same for the different major etiologies of paediatric cardiac arrest. In addition, the intubation success rate (57% for the trial overall) was low compared with more recent studies.
      Where does this leave us? Let us be frank: If TI or other advanced airway interventions were an innovative new therapy, they would not be accepted for addition to our treatment algorithms.
      Why, then, do so many resuscitation systems and providers continue to perform advanced airway interventions in paediatric cardiac arrest? It is tempting to point out that TI capability is a point of pride and ego for paramedics, emergency physicians, anesthesiologists, and others. But as “Pride goes before destruction, and a haughty spirit before a fall,”

      The Bible [New King Janes Version]. Proverbs 16:18.

      so we would not advocate intubating children because advanced health care providers are proud to have mastered this advanced skill. Another frequent argument is that resuscitation providers need to perform TI in cardiac arrest in order to maintain the skill necessary to intubate patients with apnea or airway reflex loss from other causes, and to stabilize children after ROSC. While this argument is at least patient-centric, it is difficult to think of another situation in which unconsenting patients are exposed to an invasive intervention of unproven benefit, with some risk of harm, because other patients may later benefit.
      Where do we go from here?
      It is tempting to call for “more study.” Indeed, it is difficult to consider abandoning a long-established therapy with an attractive physiologic rational for benefit based on observational data. We would all like a clinical trial – one conducted with the rigor of Gausche’s, but enrolling enough infants, children, and adolescents to identify the best airway management strategy for cardiac, asphyxial, and traumatic cardiac arrest. The sober truth is that such a study is logistically and financially daunting. There are about 73 million infants, children, and adolescents in the US, of whom about 7,000 (0.01%) suffer OHCA and 15,200 (0.02%) suffer IHCA per year.

      US Census Bureau. 2019 American Community Survey, Table DP05. Available at data.census.gov, accessed Sept 17, 2021.

      • Virani S.S.
      • Alonso A.
      • Aparicio H.J.
      • et al.
      Heart Disease and Stroke Statistics—2021 Update: A Report From the American Heart Association.
      • Holmberg M.J.
      • Ross C.E.
      • Fitzmaurice G.M.
      • et al.
      Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States.
      Paediatric OHCA is about 2% as common as adult OHCA in the US
      • Virani S.S.
      • Alonso A.
      • Aparicio H.J.
      • et al.
      Heart Disease and Stroke Statistics—2021 Update: A Report From the American Heart Association.
      , and paediatric IHCA is approximately 5% as common
      • Holmberg M.J.
      • Ross C.E.
      • Fitzmaurice G.M.
      • et al.
      Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States.
      . Gausche’s ambitious trial enrolled only 591 infants and children in cardiac arrest from a population of approximately 3 million, over a study period of 32.5 months.

      Gausche M, Lewis RJ, Stratton SJ et al. Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study. JAMA 2000;283:783-90. https://doi.org/10.1001/jama.283.6.783.

      The definitive clinical trial data we seek won’t come soon, if at all.
      A prominent American politician once said, “You go to war with the army you have, not the army you might want or wish to have at a later time.”

      Rumsfeld D, quoted in: Schmitt E. Iraq-Bound Troops Confront Rumsfeld Over Lack of Armor. The New York Times, Dec 8, 2004. Available at https://www.nytimes.com/2004/12/08/international/middleeast/iraqbound-troops-confront-rumsfeld-over-lack-of.html, accessed Sept 17, 2021.

      Le Bastard and colleagues have provided us with the third and largest sophisticated retrospective analysis of advanced airway interventions in paediatric OHCA.
      • Hansen M.L.
      • Lin A.
      • Eriksson C.
      • et al.
      A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database.
      • Ohashi-Fukuda N.
      • Fukuda T.
      • Doi K.
      • Morimura N.
      Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest.

      Le Bastard Q, Rouzioux J, Montassier E, et al. Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study. Resuscitation 2021;168:191–198. https://doi.org/10.1016/j.resuscitation.2021.08.015.

      All found that harm is associated with intubation. Although there are far fewer data for IHCA, the one methodologically excellent available study supports the same conclusion.
      • Andersen L.W.
      • Raymond T.T.
      • Berg R.A.
      • et al.
      Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival.
      Although studies are mixed, data from adult OHCA and IHCA also do not show a consistent benefit from advanced airway interventions.
      • Granfeldt A.
      • Avis S.R.
      • Nicholson T.C.
      • et al.
      Advanced airway management during adult cardiac arrest: A systematic review.
      Unless we are willing to rely solely on data from 591 children in Gausche’s trial, we should embrace BMV as the airway of choice during paediatric cardiac arrest.

      Conflict of interest statement

      Dr. Lavonas was compensated by the American Heart Association as Senior Scientific Editor of the 2020 AHA Guidelines for CPR and Emergency Cardiac Care, and by the International Liaison Committee on Resuscitation for a 2019 systematic review on advanced airway interventions in paediatric cardiac arrest.

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