PLS 4120.02 and PLS 4080.28 Ventilation parameters during cardiac arrest in children TF SR

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:

• Ian Drennan: Funding from ZOLL for study examining real-time ventilation feedback and a trial on ventilation

• Nicholas Johnson: Funding from American Heart Association for study examining ventilation parameters during CPR

• Guillaume Debaty: Published previous studies on ventilation during CPR.

• Betty Yang: Funding from American Heart Association for study examining ventilation parameters during CPR

CoSTR Citation:

del Castillo J, Johnson NJ, Debaty G, Yang BY, Moskowitz A, Drennan I, Bray JE, Olasveengen T, Acworth J, Scholefield BR, Morrison LJ on behalf of the International Liaison Committee on Resuscitation Basic Life Support, Advanced Life Support, and Pediatric Life Support Task Forces. Ventilation Parameters during Cardiopulmonary Resuscitation Consensus on Science with Treatment Recommendations: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support, Advanced Life Support, and Pediatric Life Support Task Forces, 2026. 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 of basic life support (Ashoor, 2017, 50300 – PROSPERO CRD420251070065) conducted by the Knowledge Synthesis Unit at St Michael’s Hospital, Toronto, Canada with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support, Adult Life Support, and Pediatric Life Support Task Forces respectively. 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

Johnson NJ, Debaty G, Yang BY, Moskowitz A, Drennan I, del Castillo J, Bray JE, Olasveengen T, Morrison LJ on behalf of the International Liaison Committee on Resuscitation Basic Life Support, Advanced Life Support, and Pediatric Life Support Task Forces. Ventilation Parameters during Cardiopulmonary Resuscitation Consensus on Science with Treatment Recommendations: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support, Advanced Life Support, and Pediatric Life Support Task Forces, 2026. Available from: http://ilcor.org

PICOST

PROSPERO Registration CRD420251070065

Consensus on Science

Out of 3021 titles and abstracts screened, we found 13 eligible studies. Of these, 3 were randomized controlled trials^3-5 and 10 were observational studies^6-15 .Two pediatric observational studies were found and included.^6,7

In summary, the body of evidence assessing ventilation rate, tidal volume, and adequacy (impedance-detected chest rise) during CPR is very low certainty due to serious risk of bias, inconsistency, indirectness, and imprecision. Data come primarily from observational studies and small RCTs involving heterogeneous patient populations (adult and pediatric, IHCA and OHCA), differing airway management strategies, and various measurement methods. In translating the findings of this nodal CoSTR to pediatric practice, the PLS Task Force determined that the adult evidence was not appropriate to inform pediatric treatment recommendations. Although several studies in adults were included in the review, the quality of this evidence was very low, with significant heterogeneity in patient populations, arrest settings, airway strategies (basic vs. advanced), ventilation delivery methods (manual vs. mechanical), and ventilation measurement techniques. This heterogeneity resulted in substantial inconsistency and indirectness, limiting the interpretability and generalizability of the findings in adults to children. Therefore, the PLS Task Force agreed that the adult data did not meet the threshold required for extrapolation to pediatric recommendations.

Among the included evidence, both pediatric studies evaluated ventilation rate. No pediatric studies were identified that evaluated tidal volume targets, inspiratory time, or PEEP during CPR.

Studies comparing different ventilation rates:

Survival to hospital discharge with favorable neurological outcome:

For the critical outcome of survival to hospital discharge with favorable neurological outcome: we identified very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness) from one study of 47 children with in-hospital cardiac arrest (IHCA).⁶ In this study a ventilation rate of > 30 breaths per minute in children <1 year and >25 breaths per minute in children >1 year was associated with higher odds of neurologically-intact survival (4.43 [95% CI 1.17-19.13]) compared with a ventilation rate of ≤30 breaths per minute in children <1 year and ≤25 breaths per minute in children >1 year.⁶

Survival to hospital discharge:

For the critical outcome of survival to hospital discharge or 30 days: we identified very low-certainty evidence (downgraded for risk of bias, imprecision and indirectness) from 1 observational study comparing higher with lower ventilation rates.⁶ In the above study of 47 children with in-hospital cardiac arrest (IHCA), a ventilation rate of > 30 breaths per minute in children <1 year and >25 breaths per minute in children >1 year was associated with higher odds of survival (unadjusted OR 4.73 [95% CI 1.17-19.13]) compared with a ventilation rate of ≤30 breaths per minute in children <1 year and ≤25 breaths per minute in children >1 year.⁶

Return of Spontaneous Circulation (ROSC):

For the critical outcome of ROSC: we identified very low-certainty evidence (downgraded for risk of bias, imprecision and indirectness) from 1 non-RCT comparing higher to lower ventilation rates in 47 children with IHCA. A higher ventilation rate was associated with higher odds of ROSC (unadjusted odds ratio [OR] 4.64 [95% confidence interval (CI) 1.32-16.27]).⁶ We identified very low-certainty evidence (downgraded for risk of bias, imprecision and indirectness) from one retrospective cohort (n=30 with analyzable capnography) in pediatric OHCA with either a supraglottic or advanced airway in place. Ventilations were measured by capnographic waveform algorithm validated in adults. Higher mean ventilation rates were associated with ROSC vs non-ROSC (9.2 vs 7.0 breaths/min; p<0.001).⁷

Treatment Recommendations and Good Practice Statement

For children in cardiac arrest with an advanced airway, a ventilation rate greater than 25 breaths per minute (bpm) in children 1 year of age and a ventilation rate greater than 30 bpm in children <1 year of age may be reasonable targets. (Good Practice Statement).

It is reasonable to measure ventilation rate and adequacy of tidal volume delivery and avoiding hypoventilation. (Good Practice Statement).

There is currently no evidence to make a treatment recommendation on the upper limit for ventilation rate, tidal volume delivery, inspiratory time, and/or positive end-expiratory pressure during pediatric cardiac arrest.

Justification and Evidence to Decision Framework Highlights

This topic was prioritized by the BLS, ALS, and PLS Task Forces as a nodal review based on multiple recent observational studies^9,10 demonstrating association between ventilation parameters and outcomes as well as several small randomized trials.

Ventilation during cardiac arrest encompasses multiple components including rate, volume, delivery and monitoring, as well as airway devices, feedback, and integration with chest compressions.

The previous ILCOR systematic review on pediatric ventilation rates performed in 2024¹⁶ did not identify any pediatric comparative studies evaluating specific ventilation rates, and therefore no direct pediatric evidence was available to guide rate recommendations.

The Task Force collaborated with the Basic Life Support and Advance Life Support Taskforces with an edited PICOST to conduct a much broader systematic review that would notably include two published pediatric observational studies^6,7, providing the first comparative pediatric data evaluating ventilation rate during cardiac arrest. In the prior review, these data could only be considered indirect as the original PICOST was quite prescriptive, and treatment recommendations were based largely on adult evidence and physiologic rationale. Despite the addition of these studies, the Task Force noted that the certainty of evidence remains very low, predominantly derived from pediatric in-hospital settings with an advanced airway and capnography in place.

The Task Force further discussed that the ventilation rates associated with improved outcomes in Sutton 2019⁶ were inferred from spline-based analyses rather than from prespecified comparisons. The cubic spline analysis suggested stable survival between 25 and 35 breaths/min for children older than 1 year of age and between 30 to 50 breaths/min for children younger than 1 year old, the actual ventilation rates delivered in practice were frequently even higher, and the study design did not allow determination of a causal or optimal target for ventilation rates.

While this analysis provides helpful physiologic and observational context, it remains exploratory and should not be interpreted as defining an optimal ventilation rate or thresholds. However, when considered together with the more recent out-of-hospital evidence⁷, which similarly observed higher mean ventilation rates among children who achieved ROSC albeit the breaths per minute rate were much lower, the Task Force supports the overall conclusion that higher—rather than lower—ventilation rates were associated with improved outcomes in the available pediatric data, although certainty remains very low.

Because of these limitations, the PLS Task Force agreed that the evidence was insufficient to establish an optimal ventilation rate in children, and that no comparative pediatric data exist to inform ventilation rate in out-of-hospital arrest or in non-intubated patients. No pediatric studies have evaluated optimal tidal volume delivery or PEEP during CPR.

The use of the adult algorithm measuring ventilation using ETCO₂ waveform capnography needs validation in pediatric patients. The study by Stanton 2025⁷ suggested it was feasible to use, however ventilation rates observed in the study fall well below rates associated with the best outcomes.

EtD: PLS 4120 02 4080 28 v3 0 Grade ETD SAC approved

Knowledge Gaps

• Optimal ventilation targets for children in cardiac arrest remain uncertain. Evidence informing ventilation rate comes from a single small study of pediatric in-hospital cardiac arrest with an advanced airway; the ideal ventilation rate for out-of-hospital arrest and for non-intubated patients has not been studied.
• The effects of tidal volume and delivery, inspiratory pressure, and PEEP during pediatric CPR are unknown. No comparative pediatric data exist to guide tidal volume delivery, minute ventilation, or PEEP selection, pressure settings nor to evaluate how these variables influence oxygenation, hemodynamics, or lung injury during resuscitation.
• The physiologic consequences of hypo- and hyperventilation require further study. The impact of ventilation rate on blood gases (PaCO₂, PaO₂), pH, cerebral perfusion, and blood pressure during CPR has not been systematically evaluated.
• Etiology-specific ventilation strategies are not defined. It is unclear whether optimal ventilation targets differ among arrests related to respiratory failure, cardiac etiology, drowning, or pulmonary injury.
• The influence of airway strategy on optimal ventilation parameters is not known. Additional research is needed to clarify whether recommended ventilation rates and volumes should differ between bag-mask ventilation, supraglottic airway, and endotracheal intubation.
• High-quality pediatric trials are lacking. No adequately powered randomized or prospective pediatric studies have evaluated ventilation strategies with neurologically-intact survival as a primary outcome.

References

1. Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Bottiger BW, Brooks A, Castren M, Ong ME, Hazinski MF, et al. COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation. 2018;137:e783-e801. doi: 10.1161/CIR.0000000000000562

10.1161/CIR.0000000000000562. Epub 2018 Apr 26.

2. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, Maconochie I, Nadkarni VM, de Caen A, Escalante-Kanashiro R, et al. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation. 2021;162:351-364. doi: 10.1016/j.resuscitation.2021.01.023

3. Prause G, Zoidl P, Eichinger M, Eichlseder M, Orlob S, Ruhdorfer F, Honnef G, Metnitz PGH, Zajic P. Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation. 2023;187:109765. doi: 10.1016/j.resuscitation.2023.109765

4. Langhelle A, Sunde K, Wik L, Steen PA. Arterial blood-gases with 500- versus 1000-ml tidal volumes during out-of-hospital CPR. Resuscitation. 2000;45:27-33. doi: 10.1016/s0300-9572(00)00162-3

5. Shin J, Lee HJ, Jin KN, Shin JH, You KM, Lee SGW, Jung JH, Song KJ, Pak J, Park TY, et al. Automatic Mechanical Ventilation vs Manual Bag Ventilation During CPR: A Pilot Randomized Controlled Trial. Chest. 2024;166:311-320. doi: 10.1016/j.chest.2024.02.020

6. Sutton RM, Reeder RW, Landis WP, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, et al. Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019;47:1627-1636. doi: 10.1097/CCM.0000000000003898

7. Stanton K, Mershad A, Kadish C, Murphy A, Lowe R, Ania I, Elola A, Aramendi E, Hansen M, Panchal AR, et al. Ventilation Rates and Capnography in Pediatric Out-of-Hospital Cardiac Arrest with Advanced Airways. Prehosp Emerg Care. 2025;29:1072-1077. doi: 10.1080/10903127.2025.2496756

8. Wang HE, Jaureguibeitia X, Aramendi E, Nichol G, Aufderheide T, Daya MR, Hansen M, Nassal M, Panchal AR, Nikolla DA, et al. Airway strategy and ventilation rates in the pragmatic airway resuscitation trial. Resuscitation. 2022;176:80-87. doi: 10.1016/j.resuscitation.2022.05.008

9. Chang MP, Lu Y, Leroux B, Aramendi Ecenarro E, Owens P, Wang HE, Idris AH. Association of ventilation with outcomes from out-of-hospital cardiac arrest. Resuscitation. 2019;141:174-181. doi: 10.1016/j.resuscitation.2019.05.006

10. Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, et al. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023;148:1847-1856. doi: 10.1161/CIRCULATIONAHA.123.065561

11. Vissers G, Duchatelet C, Huybrechts SA, Wouters K, Hachimi-Idrissi S, Monsieurs KG. The effect of ventilation rate on outcome in adults receiving cardiopulmonary resuscitation. Resuscitation. 2019;138:243-249. doi: 10.1016/j.resuscitation.2019.03.037

12. Snyder BD, Van Dyke MR, Walker RG, Latimer AJ, Grabman BC, Maynard C, Rea TD, Johnson NJ, Sayre MR, Counts CR. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation. 2023;193:109991. doi: 10.1016/j.resuscitation.2023.109991

13. Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004;32:S345-351. doi: 10.1097/01.ccm.0000134335.46859.09

14. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960-1965. doi: 10.1161/01.CIR.0000126594.79136.61

15. Jaffe IS RY, Tran L, et al. . Higher Ventilation Rate is Associated with Increased Return of Spontaneous Circulation in In-Hospital Cardiac Arrest Patients with Advanced Airways. . Resuscitation. 2025.

16. Scholefield BR AJ, Ng K-C, Tiwari LK, Raymond TT, Christoff A,, Katzenschlager S E-KR, Bansal A, Topjian A, Kleinman M, Kurosawa H, Myburgh MC, del Castillo J, Rossano J, Djakow J, Guerguerian A-M, Nadkarni VM, Bittencourt Couto T, Schexnayder SM, Nuthall G, Tijssen JA, Ong GY-K, Gray JM, Lopez-Herce J, Ambunda ES, Nolan JP, Berg KM, Morrison LJ, Atkins DL, de Caen AR; on behalf of the Pediatric Life Support Task Force Collaborators. Pediatric life support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Resuscitation. 2025;215. doi: doi.org/10.1016/j.resuscitation.2025.110813