Clinical paperProspective evaluation of airway management in pediatric out-of-hospital cardiac arrest
Introduction
Pediatric out-of-hospital cardiac arrest (OHCA) is a rare but devastating condition which affects approximately 15,000 children each year with 8–12% survival.1, 2 Airway management interventions may be particularly important in children since many arrests are related to primary respiratory problems. Airway management techniques may have a direct effect on outcomes or may influence outcomes by impacting other aspects of care during resuscitation, such as quality of CPR, timely medication administration, and complications such as pneumothorax or pneumonia. During prehospital pediatric simulation training, we observed a tendency to prioritize advanced airway management before other aspects of resuscitation including medications. Several studies have recently suggested that more rapid administration of the initial dose of epinephrine is associated with improved OHCA outcomes in both children and adults.3, 4, 5 Therefore, identifying resuscitation practices associated with a shorter time to the initial dose of epinephrine may be beneficial. Since airway management strategies differ in complexity and speed, the airway management strategy could significantly impact the timing of the initial dose of epinephrine.
Currently, EMS providers have three airway management options for pediatric OHCA, including bag-mask-ventilation (BMV) without an advanced airway (BVM-only), supraglottic airway devices (SGA), and tracheal intubation (TI). TI is the most common modality used despite its potential pitfalls as a complex procedure which is rare for any individual paramedic to perform during their career.6, 7, 8 Since TI is a more complex procedure, we suspected it could be associated with delays in epinephrine administration. A previous randomized trial found that BMV was equivalent to TI in children, though this study was not limited to OHCA.9 SGAs have recently been deployed by EMS systems for pediatric patients after having success in adult OHCA.10 Since BMV and SGA are likely faster to implement than TI, we hypothesized that these techniques would be associated with shorter times to the initial dose of epinephrine.
The primary objective of this study was to determine the association between airway management strategy and time to the initial dose of epinephrine in pediatric patients with OHCA. Our secondary goal was to evaluate the success rates of TI and SGA in pediatric OHCA, evaluate airway rescue techniques, and report complications including pneumothorax, airway damage, and pneumonia.
Section snippets
Design
We conducted a prospective observational study of pediatric airway management as a sub-study of the adult Pragmatic Airway Resuscitation Trial (PART).10, 11 Two of the five sites (Dallas, Texas, and Portland, Oregon) in the PART trial participated in this study. The same study personnel, data collection processes, data collection forms, and data quality assurance processes were used for both studies. IRB approval was obtained at both of these sites.
Study setting and participants
This study was conducted among 10 EMS
Patient characteristics
The study included a total of 155 patients (after excluding one patient with significant facial trauma) with 55% of the patients less than age one and 64% female. Seventy-three percent of arrests were witnessed and 60% had bystander CPR. Baseline patient characteristics are included in Table 1 by the first airway attempted. Enrollment occurred from April 2016 to April 2018.
Study outcomes
Table 2 displays the unadjusted analyses for time to the initial dose of epinephrine and time to the first successful
Discussion
In this prospective observational study of 155 pediatric OHCAs, the airway management strategy was not associated with time to the initial dose of epinephrine in the adjusted analysis. This offers preliminary evidence that an initial airway strategy of TI may not significantly distract from medication administration and is similar to findings recently reported from the adult PART trial data.12 However, both EMS systems in this study are designed to have a relatively high number of paramedics on
Conclusions
Among children with OHCA, the airway management strategy was not associated with time to the initial dose of epinephrine. The complication of pneumonia was unexpectedly high among those treated with advanced airways. TI was the most common initial advanced airway management strategy used though first placement success was low with TI and high with SGA. A randomized trial is needed to determine optimal airway management for pediatric OHCA.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose
Funding source
This study was funded by a K23 grant from the National Heart Lung and Blood Institute (NHLBI) grant numbers K23HL131440. The Resuscitation Outcomes Consortium institutions participating in the study were supported by a series of cooperative agreements from the National Heart, Lung and Blood Institute, including 5U01 HL077863 (University of Washington n Data Coordinating Center), HL077873 (Oregon Health and Science University), HL077887 (University of Texas Southwestern Medical Center/Dallas).
Conflicts of interest
The authors have no conflicts of interest relevant to this article to disclose.
CRediT authorship contribution statement
Matt Hansen: Conceptualization, Methodology, Writing - review & editing, Writing - original draft, Data curation, Formal analysis. Henry Wang: Conceptualization, Methodology, Writing - review & editing. Nancy Le: Conceptualization, Methodology, Writing - review & editing, Data curation, Project administration, Investigation. Amber Lin: Writing - original draft, Data curation, Formal analysis. Ahamed Idris: Conceptualization, Methodology, Writing - review & editing. Joshua Kornegay: Methodology,
Acknowledgments
This study was funded by grants from the National Heart Lung and Blood Institute (NHLBI) grant numbers K23HL131440, 5U01 HL077863, HL077873, and HL077887. The NHLBI did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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