Time to Advanced Airway Management in Pediatric Out-of-Hospital Cardiac Arrest

Endotrachel tube, mechanical ventilation
How is the survival of children experiencing out-of-hospital cardiac arrest affected by the timing of advanced airway management?

A delay in advanced airway management (AAM) in children experiencing out-of-hospital cardiac arrest (OHCA) is associated with worse survival 1 month post OHCA,  according to study findings published in Resuscitation Plus.

Pediatric advanced airway management (AAM) — ie, the insertion of endotracheal tube, laryngeal mask airway or laryngeal tube — may lower the risk of aspiration and improve ventilation during OHCA. However, this critical aspect of pediatric resuscitation may be difficult to achieve in a timely manner, given the need for specialized equipment and providers with proper training.

Researchers in Japan sought to evaluate outcomes associated with time to AAM following OHCA in children. The primary endpoint was 1-month overall survival. Secondary endpoints were 1-month neurologically favorable survival and prehospital return of spontaneous circulation (ROSC). The nationwide, population-based observational study included Japanese government registry data on 761 children, aged 1 to 17 years (mean age 12.7±4.8 years), who underwent OHCA and were treated with AAM from 2014 to 2019. All patients were treated by emergency medical service personnel before arriving at a hospital. Associations between time in minutes from emergency call to the first successful AAM and the outcomes following OHCA were evaluated with multivariable logistic regression models.

The investigators found the mean time to AAM was 18.9±7.9 minutes, and that following OHCA, 77 (10.1%) patients survived 1 month. Greater time to AAM was significantly associated with decreased chance of 1-month survival after adjusting for possible confounders (multivariable adjusted OR per minute delay 0.93; 95% CI, 0.89-0.97; P =.001). Decreased rates of neurologically favorable survival (adjusted OR 0.83; 95% CI, 0.72-0.95; P =.006) and prehospital ROSC (adjusted OR 0.94; 95% CI, 0.90-0.99; P =.01) were also significantly associated with greater time to AAM. Researchers noted that the delayed time to AAM association with survival remained consistent through sensitivity and subgroup analysis.

Study limitations include resuscitation time bias, selection bias, the observational study design, and limited generalizability of findings, particularly to children under 8 years of age, infants, and children from other countries. Additional limitations include lack of data on failed AAM attempts, misclassification of time variables, and underpowered sample size.

“Among pediatric OHCA patients, delayed AAM was associated with a decreased chance of survival, although the influence of resuscitation time bias might remain,” said investigators, adding that further prospective studies accounting for a greater range of variables are needed.


Ohashi-Fukuda N, Fukuda T, Doi K. Association between time to advanced airway management and survival during pediatric out-of-hospital cardiac arrest. Resusc Plus. Published online June 24, 2022. doi:10.1016/j.resplu.2022.100260