Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
CoSTR Citation
Jason Acworth, Jimena del Castillo, Elliott Acworth, Lokesh Tiwari, Jesus Lopez-Herce, Eric Lavonas, Laurie Morrison, on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Advanced Airway Interventions in Pediatric Cardiac Arrest - Paediatric Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Paediatric Advanced Life Support Task Force, 2024 January xxxxx. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (Acworth, 2023, PROSPERO CRD pending) which was an update from the previously performed systematic review (Lavonas, 2018, PROSPERO CRD42018102430) conducted by the members of the PLS TF with involvement of clinical content experts. Evidence for pediatric literature was updated and considered by the Pediatric Life Support Task Force. Additional scientific literature was published after the completion of the systematic review and identified by the Pediatric Task Force and is described before the justifications and evidence to decision highlights section of this CoSTR. These data were taken into account when formulating the Treatment Recommendations.
Systematic Review
Acworth J et al. Advanced Airway Interventions in Pediatric Cardiac Arrest (in preparation)
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children who had received CPR after out-of-hospital or in-hospital cardiac arrest (excluding newborn children)
Intervention: Placement of an advanced airway device
Comparators: Compared with bag-mask-ventilation (BMV) alone or with non–advanced airway interventions (Primary); or another advanced airway device (Secondary)
Outcomes: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract.
Timeframe: As this is an update to a previously published ILCOR systematic review, all studies published since most recent search date (September 24, 2018) will be included and added to those from the original systematic review for analysis. The search will include publication dates from June 2018 onwards to ensure no articles are missed. The last search was performed on 15 August 2023.
PROSPERO Registration: Under review at PROSPERO (Date of submission 13 November 2023)
Consensus on Science
Nineteen studies were included in the systematic review. Only 1 study provided clinical trial data. (Gausche 2000 783) Five studies provided propensity-adjusted cohort data. (Andersen 2016 1786) (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9) Nine other studies provided retrospective cohort data amenable to meta-analysis. (Abe 2012 612) (Aijian 1989 489) (Deasy 2010 1095) (del Castillo 2015 340) (Guay 2004 373) (Handley 2021 14) (Hansen 2020 53) (Pitetti 2002 283) (Sirbaugh 1999 174) Four studies provided retrospective cohort data in adjusted form only, not amenable to meta-analysis.(Fink 2016 121) (Tijssen 2015 1) (LeBastard 2021 191) (Cheng 2021 723327) One study (Tham 2018 111) that was included in the original systematic review (Lavonas 2019 114) was excluded from this updated systematic review due to overlap with a newer study. (Tham 2022 9)
All results are presented as Risk Ratios (RR) and absolute Risk Difference (aRD) and our assessment of statistical significance is based on the absolute risk reduction 95% confidence interval (CI 95%). A random effects model was chosen for meta-analysis to better account for study heterogeneity.
Studies comparing tracheal intubation (TI) with bag mask ventilation alone (BMV):
Survival with good neurologic outcome (SGNO)
For this critical outcome, we identified low certainty evidence downgraded for indirectness (resuscitations conducted prior to 2000, when standard resuscitation was different than current practice) and imprecision from 1 quasi-randomised controlled trial. (Gausche 2000 783) This study assigned 591 children with out-of-hospital cardiac arrest (OHCA) to TI or BMV and found no statistical benefit or harm associated with use of TI (RR 0.69, CI 95%: 0.32-1.52; absolute risk difference aRD: 15 fewer children surviving with good neurologic outcome per 1,000 randomised to TI; CI 95%: 34 fewer to 26 more).
Additionally, very low certainty evidence comes from five propensity-adjusted cohort studies, downgraded because none could differentiate children with failed attempts at TI from those in whom TI was not attempted (risk of bias). (Andersen 2016 1786) (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9) These studies included 4,093 children with in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) and found no statistical benefit or harm associated with use of the TI intervention (RR 0.54, CI 95%: 0.29-1.00; aRD: 67 fewer survivors per 1,000 resuscitations; CI 95%: 104 fewer to 0 fewer). These studies had heterogeneous results (I2: 73%) In addition, very low certainty evidence is available from 2 cohort studies involving 372 children which found apparent harm associated with the use of TI (RR 0.76, CI 95%: 0.61-0.95; aRD: 131 fewer survivors per 1,000 resuscitations; CI 95%: 212 fewer to 27 fewer).(del Castillo 2015 340) (Sirbaugh 1999 174)
Very low certainty evidence is available from 4 further observational studies with data not amenable to meta-analysis. Two studies found no statistical benefit or harm from advanced airway interventions (pooled TI/SGA but TI used in >90% in each) compared to BMV (Fink 2016 121: adjusted odds ratio (aOR) 0.64, CI 95%: 0.37 – 1.13; Tijssen 2015 1: aOR 0.69, CI 95%: 0.43 – 1.10). One small study (Cheng 2021 723327) reported a protective effect of advanced airway interventions (pooled TI/SGA - %TI unreported) compared to BMV for SHD (OR 8.95, 95%CI 1.41-66.08) and SGNO (OR 8.95, 95%CI 1.41-66.08). One larger study (Le Bastard 2021 168) reported both lower SHD (7.7% vs 14.3%, p=0.002) and lower SGNO (4.6% vs 11.1%, p<0.001) for TI compared to SGA/BMV.
Survival to hospital discharge
For this critical outcome, we identified low certainty evidence from one clinical trial of 591 children. (Gausche 2000 783) No apparent association was found between TI and survival (RR 1.04, CI 95%: 0.60-1.79; aRD: 3 more patients surviving to discharge per 1,000 assigned to TI; CI 95%: 32 fewer to 63 more).
Very low certainty evidence is provided by 5 propensity-adjusted cohort studies including 4,393 children. (Andersen 2016 1786) (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9) No apparent association was found between TI and survival (RR 0.72, CI 95%: 0.48-1.07; aRD: 73 fewer patients surviving to discharge per 1,000 assigned to TI; CI 95%: 136 fewer to 18 more).
Combined data from 8 observational studies involving 7,392 patients were highly discordant (I2: 88%).(Abe 2012 612) (Aijian 1989 489) (Deasy 2010 1095) (Guay 2004 373) (Handley 2021 14) (Hansen 2020 53) (Pitetti 2002 283) (Sirbaugh 1999 174) No apparent association was found between TI and survival (RR 0.85, CI 95%: 0.40-1.78; aRD: 29 fewer patients surviving to discharge per 1,000 assigned to TI; CI 95%: 118 fewer to 153 more).
Summary of findings
These results suggest that resuscitation with tracheal intubation is not superior to BMV-based resuscitation for cardiac arrest in children for the critically important outcomes of survival with good neurologic outcomes and survival to hospital discharge (with low to very low certainty). Some very low certainty evidence suggests the use of TI may be associated with harm.
Studies comparing supraglottic airway placement (SGA) with bag mask ventilation alone (BMV):
Survival with good neurologic outcome
For this critical outcome, very low certainty evidence obtained from 4 propensity-adjusted cohort studies involving 3,123 patients showed no statistical benefit or harm associated with SGA ventilation (RR 0.57, CI 95%: 0.26-1.23; aRD: 33 fewer survivors per 1,000 resuscitations; CI 95%: 56 fewer to 18 more). (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9)
Survival to hospital discharge
For this critical outcome, very low certainty evidence obtained from 4 propensity-adjusted cohort studies involving 3,123 patients showed no statistical benefit or harm associated with SGA ventilation (RR 0.89, CI 95%: 0.54-1.46; aRD: 14 fewer survivors per 1,000 resuscitations; CI 95%: 58 fewer to 58 more). (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9)
Additional very low certainty evidence from two observational studies of 3,085 children found no significant treatment association (RR 0.53, CI 95%: 0.21-1.34; aRD: 43 fewer survivors per 1,000 treated with SGA; CI 95%: 71 fewer to 31 more).(Abe 2012 612) (Hansen 2020 53)
Summary of findings
Recognizing the fact that there are conflicting and uncertain study results, the overall data are most consistent with no treatment effect associated with SGA ventilation when compared with BMV.
Studies comparing tracheal intubation (TI) with supraglottic airway placement (SGA):
No clinical trial studied the impact of SGA placement on resuscitation outcomes. The best available evidence is observational and of very low certainty.
Survival with good neurologic outcome
For this critical outcome, very low certainty evidence is available from 3 propensity-matched cohort studies enrolling 1,514 children. (Fukuda 2020 145) (Hansen 2017 51) (Ohashi-Fukuda 2017 66) When combined, these studies showed no statistical benefit or harm to either intervention (RR 0.80, CI 95%: 0.44-1.43; aRD: 8 fewer neurologically intact survivors per 1,000 patients managed with TI rather than SGA; CI 95%: 23 fewer to 17 more). Additional very low certainty evidence is provided by a cohort study of 452 patients, which also found no statistical advantage to either modality (RR 2.75, CI 95%: 0.67-11.27; aRD: 24 more survivors with TI; CI 95%: 4 fewer to 138 more). (Tham 2022 9)
Survival to hospital discharge
Similar to the above, for this critical outcome, very low certainty evidence from 3 propensity-matched cohort studies of 1,514 patients found no statistical benefit or harm associated with TI or SGA (RR 0.80, CI 95%: 0.55-1.15; aRD: 25 fewer survivors per 1,000 patients managed with TI rather than SGA; CI 95%: 57 fewer to 19 more). (Fukuda 2020 145) (Hansen 2017 51) (Ohashi-Fukuda 2017 66) Similar results were obtained from 3 cohort studies involving 1007 children (RR 1.35, CI 95%: 0.82-2.22; aRD: 24 more survivors per 1,000 patients managed with TI rather than SGA; CI 95%: 12 fewer to 82 more). (Abe 2012 612) (Hansen 2020 53) (Tham 2022 9)
Summary of findings
There are no significant differences in outcomes shown between the use of TI or SGA in pediatric resuscitation based on limited and contradictory evidence of very low certainty.
Subgroup Analyses
In-hospital cardiac arrest (IHCA) vs. out-of-hospital cardiac arrest (OHCA)
Separate analyses of studies of IHCA and OHCA produced similar results. However, the body of evidence for IHCA is particularly small (consisting of 1 propensity-matched cohort study and 3 other cohort studies) and provides very low certainty evidence. (Andersen 2016 1786) (del Castillo 2015 340) (Guay 2004 373) (Handley 2021 165) The studies are very heterogenous and showed inconsistent results.
Studies comparing tracheal intubation (TI) with bag mask ventilation alone (BMV): OHCA
Low certainty evidence from one quasi-randomised controlled trial (Gausche 2000 783) involving 591 children found no statistical effect on SGNO associated with use of TI in pediatric OHCA (RR 0.69, CI 95%: 0.32-1.52; aRD: 15 fewer children surviving with good neurologic outcome per 1,000 randomised to TI; CI 95%: 34 fewer to 26 more). Similarly, the study reported no statistical effect on SHD (RR 1.04, CI 95%: 0.60-1.79; absolute risk difference aRD: 3 more children surviving to discharge per 1,000 randomised to TI; CI 95%: 32 fewer to 63 more).
Very low certainty evidence from 4 propensity-adjusted cohort studies of children with OHCA found a lower rate of SGNO with use of TI (RR 0.41, CI 95%: 0.28-0.58; aRD: 54 fewer survivors with good neurological outcomes per 1,000 resuscitations; CI 95%: 66 fewer to 39 fewer) and a lower rate of SHD with TI (RR 0.58, CI 95%: 0.41-0.81; aRD: 55 fewer survivors per 1,000 resuscitations; CI 95%: 77 fewer to 25 fewer). (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9).
Very low certainty evidence from one cohort study involving 248 children found no statistical effect on SGNO with use of TI (RR 0.36, CI 95%: 0.02-8.70). (Sirbaugh 1999 174) Very low certainty evidence from 6 cohort studies involving 3,726 children with OHCA also found no statistical effect on SHD with use of TI (RR 0.73, CI 95%: 0.47-1.13). (Abe 2012 612) (Aijian 1989 489) (Deasy 2010 1095) (Hansen 2020 53) (Pitetti 2002 283) (Sirbaugh 1999 174)
Studies comparing supraglottic airway placement (SGA) with bag mask ventilation alone (BMV): OHCA
Very low certainty evidence from 4 propensity-adjusted cohort studies examining children with OHCA found no statistical effect on SGNO with use of TI (RR 0.57, CI 95%: 0.26-1.23; aRD: 33 fewer survivors with good neurological outcomes per 1,000 resuscitations; CI 95%: 56 fewer to 18 more) and similarly no statistical effect on SHD with TI (RR 0.89, CI 95%: 0.54-1.46; aRD: 14 fewer survivors per 1,000 resuscitations; CI 95%: 58 fewer to 58 more). (Hansen 2017 51) (Ohashi-Fukuda 2017 66) (Okubo 2019 175) (Tham 2022 9).
Very low certainty evidence from 2 cohort studies involving 3,085 children with OHCA found no statistical effect on SHD with use of TI (RR 0.53, CI 95%: 0.21-1.34; aRD: 43 fewer survivors per 1,000 resuscitations; CI 95%: 71 fewer to 31 more). (Abe 2012 612) (Hansen 2020 53)
Studies comparing tracheal intubation (TI) with supraglottic airway placement (SGA): OHCA
All of the included studies comparing TI with SGA were performed in the OHCA setting, so subgroup analysis results are identical to that for the whole group.
Studies comparing tracheal intubation (TI) with bag mask ventilation alone (BMV): IHCA
Very low certainty evidence from one propensity-adjusted cohort study of children with IHCA found no statistical effect on SGNO with use of TI (RR 0.87, CI 95%: 0.73-1.04; aRD: 28 fewer survivors with good neurological outcomes per 1,000 resuscitations; CI 95%: 58 fewer to 9 more) and a lower rate of SHD with TI (RR 0.89, CI 95%: 0.80-0.99; aRD: 45 fewer survivors per 1,000 resuscitations; CI 95%: 81 fewer to 4 fewer). (Andersen 2016 1786)
Very low certainty evidence from a small cohort study involving 124 children with IHCA suggested a harmful effect on SGNO with use of TI (RR 0.76, CI 95%: 0.61-0.96; aRD: 195 fewer survivors with good neurological outcomes per 1,000 resuscitations; CI 95%: 316 fewer to 32 fewer). (del Castillo 2015 340) Very low certainty evidence from 2 other cohort studies involving 3,666 children with OHCA found no statistical effect on SHD with use of TI (RR 0.88, CI 95%: 0.20-3.86). (Guay 2004 373) (Handley 2021 14)
Studies comparing SGA with either TI or BMV alone: IHCA
No studies were found in the IHCA setting comparing SGA with BMV or TI with SGA.
Treatment recommendations
We suggest the use of BMV rather than TI or SGA in the management of children during cardiac arrest in the out-of-hospital setting (weak recommendation, very low certainty evidence).
There is insufficient quality evidence to make a recommendation for or against the use of the BMV compared to TI or SGA for in-hospital cardiac arrest.
The main goal of cardiopulmonary resuscitation is effective ventilation and oxygenation, by whatever means, without compromising quality of chest compressions. We suggest that clinicians consider transitioning to an advanced airway intervention (SGA or TI) when the team has sufficient expertise, resources, and equipment to allow TI/SGA placement to occur with minimal interruptions to chest compressions or when BMV is not providing adequate oxygenation/ventilation [Good Practice Statement].
Justification and Evidence to Decision Framework Highlights
There is currently no supporting evidence that an advanced airway (supraglottic airway or tracheal intubation) during CPR improves survival or survival with a good neurological outcome after pediatric cardiac arrest in any setting when compared with bag-mask ventilation.
Advanced airway interventions, particularly TI, have been long-established components of the advanced life support bundle of care in children. As a result of inherent limitations in their design and data sources, the available studies, though individually well conducted, can provide only very low certainty evidence about whether attempting advanced airway placement prior to ROSC improves resuscitation outcomes.
Most of the available data has been obtained from registries and an unknown proportion of events labelled as BMV resuscitation may have had failed TI and/or SGA attempts (which would bias against BMV). Conversely, most of the included studies are susceptible to resuscitation-time bias ie. the longer the child is in cardiac arrest, the more likely they will receive interventions but the less likely they will survive (which should bias against TI/SGA).
The best available data show no benefit from these advanced airway interventions, and some suggested association with harm, for the critical outcomes of survival with good neurologic outcome and survival to hospital discharge.
Effective BMV, TI, and SGA are all difficult skills that require good initial training, retraining, and quality control to be done consistently, safely, and effectively. Pediatric advanced airway programs require a moderate investment in equipment and a significant investment in training, skills maintenance, and quality control programs to be successful.
The decision regarding the preferred choice of airway management technique (BMV, SGA or TI) in the setting of paediatric cardiac arrest is a complex one as the benefit or harm may differ across different settings, for different ages of children, for different causes of the arrest, and depending on the experience of the resuscitation team. Importantly, the available data do not inform the questions of whether better outcomes might be achieved by different airway strategies in long distance transportation or in prolonged resuscitation situations, with highly experienced airway operators. The analyzed data are only relevant to advanced airway interventions during CPR, and do not pertain to airway management in other critical situations or once ROSC has been achieved.
Attachments: PLS 6 1 Et D Table Advanced airway interventions in pediatric cardiac arrest
Knowledge gaps
Prehospital, ED-based, and in-hospital studies, ideally comparing TI, SGA and BMV with planned subgroup analyses based on patient age and etiology of arrest (trauma vs non-trauma) are ethical, necessary, and critically important to help guide clinicians in making these complex decisions.
Further examination of the benefit of advanced airway interventions in particular settings (including patients with poor pulmonary compliance, long distance transportation) would be helpful.
The efficacy and speed of placement of advanced airway using newer technologies, such as video assisted laryngoscopy (compared to regular laryngoscopy), is not known during resuscitation and would benefit from further studies.
Measures of the quality of chest compressions and ventilations were not consistently measured in the included studies. These may be important confounders in assessment of interventions and outcomes. Future studies would benefit from including measures of quality of ventilation (& cardiac metrics), timing of airway intervention, duration of CPR and measures of the training and experience of the clinicians performing the interventions.
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