Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. No Task Force (TF) members and other authors were recused from the discussion as they declared a conflict of interest
Del Castillo J, Acworth J, López-Herce J, Kleinman M, Atkins D, on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Ventilation rates in pediatric CPR with an advanced airway - Pediatric Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric 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 of ventilation rates during cardiopulmonary resuscitation in children with an advanced airway (del Castillo 2023, PROSPERO registration number CRD42023480925) conducted by the members of the PLS TF with involvement of clinical content experts. Evidence for pediatric literature was sought and considered by the Pediatric Task Force group.
Searching on prospero for this says no hits for 42023480925
Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published – in preparation
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children (excluding newborn infants) with out-of-hospital or in-hospital cardiac arrest and an advanced airway
Intervention: Use of any specific respiratory rate
Comparators: Compared with ventilation rate of 8-10 per minute
Outcomes: P-COSCA is the preferred outcomes however the search will report all outcomes.
Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, Maconochie I, Nadkarni VM, de Caen A, Escalante-Kanashiro R, Ng KC, Nuthall G, Reis AG, Van de Voorde P, Suskauer SJ, Schexnayder SM, Hazinski MF, Slomine BS. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation. 2020 Oct 20;142(16):e246-e261. doi: 10.1161/CIR.0000000000000911. Epub 2020 Sep 24. PMID: 32967446.
Study Design: Systematic reviews. 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: All years
PROSPERO Registration CRD42023480925
Consensus on Science
No studies compared the respiratory rate of 8-10 breaths per minute with any other specific ventilatory rate.
There is currently no evidence to make a treatment recommendation on a specific ventilatory rate in pediatric cardiopulmonary resuscitation with an advanced airway.
In the absence of any literature identified in this systematic review, the Task Force suggests based on expert opinion, using ventilation rates close to age-appropriate respiratory rates with avoidance of hypoventilation and hyperventilation in pediatric cardiopulmonary resuscitation with an advanced airway in place at time of arrest. (Good Practice Statement).
The TF discussed that no study met inclusion in this SR as none specifically addressed the ventilation rate comparison that had been defined in the PICOST.
A previous treatment recommendation regarding ventilation rates was not based on a high quality systematic review of the pediatric literature. The TF concluded that the adult data was too indirect to make a recommendation in pediatric cardiac arrest. The TF agreed that the previous treatment recommendation of ventilation rates of 10 breaths/ minute during cardiac arrest was derived from adult data. The TF considered that a ventilation rate of 10 breaths/minute during cardiac arrest may cause hypoventilation in infants and children. The TF considered a single mathematical model published in 2019 which suggested higher rates had better outcomes.
In making this GPS the PLS Task Force considered the following literature which was outside the scope of this systematic review as the studies did not report a comparison arm:
- We did not identify any study that compared the actual recommendation of 8-10 breaths per minute with any other ventilation rate.
- Based on the expertise of the TF, members identified two observational studies (McInnes 2011 1025, Donoghue 2020 37) that reported ventilation rates in children during IHCA. Outcomes related to respiratory rate were not reported in either study, but they described clinical practice in ventilating patients with an advanced airway in an IHCA setting. In one (McInnes 2011 1025), patients aged from 8-18 years were included and ventilation rates above 10 breaths per minute (bpm) were observed in 63% of the cases. The second one, (Donoghue 2020 37) found that in IHCA patients with an advanced airway, mean ventilation rates observed were 24 breaths per minute, and ventilation rates higher than 8-10 bpm were observed in 66% of the cases.
- No study evaluating respiratory rates in the out-of-hospital setting was identified.
- The TF was aware of a published mathematical model in IHCA (Sutton 2019 1627) comparing observed ventilation rates with outcomes which had prompted this systematic review. The ventilation rate in the prior treatment recommendation was not observed or measured in the mathematical model. The model analyzed observed ventilation rates and outcomes of survival to hospital discharge and survival with good neurological outcome during IHCA in pediatric intensive care units. All patients had an endotracheal tube and capnography in place which could have provided some ventilation guidance for providers and thus is not generalizable in other populations or settings.
- This study evaluated the average event respiratory rates judged by capnography. The authors identified the optimal ventilatory rate for survival according to the analysis of cubic spline and Receiver Operator Characteristic curves. After controlling with a multivariable model for possible confounders, they defined optimal rate for children <1year old and >= 1 year of age. The mathematical model suggested an optimal rate for < 1year of 30 breaths/minute [AUC was 0.701 (95% CI, 0.501–0.901; optimal rate, 29.63 breaths/min; sensitivity, 0.93; specificity, 0.56); cubic spline analysis suggested stable survival rates between 30 and 50 breaths/min] and 25 breaths/minute for those >= 1 year [AUC 0.558 (95% CI, 0.274–0.842; optimal rate, 25.05 breaths/min; sensitivity, 0.75; specificity, 0.46); cubic spline analysis suggested stable survival rates between 25 and 35 breaths/min.]
- In this study the mean ventilation rate for was 30 bpm (IQR 23.4-37.4) and no patient was ventilated with a rate <14 bpm.
- Analysis of survival to hospital discharge and survival with good neurological outcome was made according to this categorization, i.e., survival to hospital discharge and survival with good neurological outcome rates in patients who had been ventilated above optimal rate threshold versus those who had been ventilated below rate threshold (<1 year 30 breaths/min >=1 year 25 breaths/min). Results were presented as Odds Ratios (OR) and assessment of statistical significance was based on the absolute risk reduction 95% confidence interval (CI 95%).
- Survival with good neurological outcome was defined as PCPC of 1 to 3 or no worsening from baseline. For the critical outcomes of survival with good neurological outcome this study found that ventilation rates >= 30 breaths/min in infants (age <1 year) and >= 25 breaths/min in children (1 year or older) respectively, were associated with an improved OR for survival with good neurologic outcome (OR 4.73; [95% CI 1.17-19.13). The overall certainty of evidence was rated as very low, primarily because of a very serious risk of bias.
- For the critical outcome of survival to hospital discharge, this study found that ventilation rates of 30 breaths/min in infants less than 1 year old and 25 breaths/min in children respectively, were associated with an improved OR for survival to hospital discharge (OR 4.73; 95% CI 1.17-19.13). The overall certainty of evidence was rated as very low, primarily because of a very serious risk of bias.
- The TF considered that the rates referred to as adequate were deemed as such based on a mathematical model of ventilation in the PICU in IHCA and cannot be generalized to other populations.
- The TF considered the potential harm of higher ventilation rates. The risk of hyperventilation resulting in hypocarbia had not been evaluated in the study and should be taken into consideration.
- The study found that high ventilation rates in children >1 year were associated with lower systolic blood pressures (-17.8 mmHg per 10 breaths/min increase; CI -2.7 to -8.1; p<0.01). The TF agreed that hyperventilation (age-specific) could compromise systolic blood pressure.
The optimal ventilation rate during continuous chest compressions in children with an advanced airway is unknown. High quality comparison trials controlling for confounders are required.
The effect of other ventilation variables (other than rate, i.e., tidal volume, minute volume, positive end-expiratory pressure) on oxygenation and ventilation during CPR requires further study. Research should investigate optimal minute ventilation along with other ventilation measurements including peak pressure, positive end-expiratory pressure, capnography and blood gas analysis.
The result of hypocarbia due to higher ventilation rates or of hypercarbia due to lower ventilation rates has not been studied and needs further assessment. Future studies should look at the influence of ventilation rates in blood gas analyses and outcomes.
The optimal ventilation rate according to cardiac arrest etiology is not known. Future studies should investigate different causes of arrest (i.e., drowning, arrhythmogenic, lung injury) and ventilation parameters accordingly.
A published mathematical model based on observational data in an ICU setting suggests that comparative studies should look at the different respiratory rates in different pediatric ages for cardiac arrest and resuscitation with an advanced airway.
Note to Webmaster: This CoSTR is not linked to any ETD summary table as no evidence was identified.
- Donoghue A, et al. Analysis of CPR quality by individual providers in the pediatric emergency department. Resuscitation 2020;153:37-44.
- McInnes AD, et al. The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents Resuscitation 2011;82(8):1025-9.
- Sutton RM, et al. Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019;47(11):1627