De Caen, Allan

Tijssen, Janice A.

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Western University Scholarship@Western Paediatrics Publications Paediatrics Department 12-20-2016 Is It Time to Stop Teaching Bystanders Ventilation as Part of Pediatric Cardiopulmonary Resuscitation? Allan De Caen University of Alberta Janice A. Tijssen Western University, janice.tijssen@lhsc.on.ca Follow this and additional works at: https://ir.lib.uwo.ca/paedpub Citation of this paper: De Caen, Allan and Tijssen, Janice A., "Is It Time to Stop Teaching Bystanders Ventilation as Part of Pediatric Cardiopulmonary Resuscitation?" (2016). Paediatrics Publications. 2117. https://ir.lib.uwo.ca/paedpub/2117 Circulation. 2016;134:2071–2073. DOI: 10.1161/CIRCULATIONAHA.116.025723 December 20/27, 2016 2071EditorialAllan de Caen, MDJanice A. Tijssen, MDEditorialarticles, see p 2046 and p 2060the International Liaison Committee on Resuscitation (ILCOR) is made up of the world’s major resuscitation councils. Part of its function is to periodically perform systematic reviews of resuscitation topics that are the foundation for council-spe-cific resuscitation guidelines for basic and advanced life support for both adults and chil-dren. ILCOR’s Pediatric Task Force regularly reviews pediatric resuscitation science to generate evidence-informed treatment recommendations to guide the care of pediatric victims of out-of-hospital cardiac arrest (OHCA).1 ILCOR’s ability to do so has historically been limited by the number and size of the pediatric studies available for its systematic reviews.For more than a decade, the All-Japan Utstein Registry of its Fire and Disaster Management Agency has prospectively collected adult and pediatric OHCA data from across Japan. The registry has an impressive history of accurate and complete data capture, with no missing, incomplete, or inconsistent data for patients included in many of its studies.2 This registry has allowed observational study of many impor-tant clinical questions. Two such questions are addressed in the 2 articles from this registry published in this issue of Circulation: What is the outcome of children with OHCA resuscitated by lay rescuers using chest compression–only cardiopulmonary resuscitation (CC-CPR) compared with conventional CPR (with ventilation)2? And what are the associations between the duration of CPR for pediatric OHCA and patient outcomes.3Bystander CPR rates in many parts of the world remain low, and the inability or unwillingness to provide ventilation as part of conventional CPR has been one of the often-cited explanations. This, coupled with the greater complexity associated with teaching lay rescuers ventilation and the interruptions to chest compressions to give breaths, has led guidelines and training organizations to encourage CC-CPR by lay rescuers for adult (primarily cardiac-based) OHCA, especially by those rescuers untrained in conventional CPR.4 To date, outcomes after bystander CC-CPR have been comparable to those after conventional CPR in adults, as supported by data from not only observational studies but also several randomized, controlled trials.5CC-CPR might be acceptable for use in adults, but what about children? As op-posed to the arrhythmic arrests commonly seen in adults, pediatric OHCA is often respiratory in origin, supporting the concept that ventilation may be more critical in pediatric resuscitation.6 ILCOR’s 2015 treatment recommendations encouraged rescuers to provide ventilation and chest compressions for pediatric OHCA victims1 and were based on pooled data from 2 studies from the All-Japan Utstein Registry, showing that the use of CC-CPR compared with conventional CPR was associated with worse 30-day intact neurological survival (risk ratio, 0.46; 95% confidence in-terval [CI], 0.34–0.62).7,8 Of these 2 studies, the Kitamura study provided more detailed analysis of subgroup outcomes based on the type of cardiac arrest, includ-is it time to Stop teaching Bystanders Ventilation as Part of Pediatric Cardiopulmonary resuscitation?© 2016 American Heart Association, Inc.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Allan de Caen, MD, Edmonton Clinic Health Authority, 11405 87 Ave, Room 4-522, Edmonton, AB, Canada T6G1C9. E-mail allan.decaen@albertahealthservices.caKey Words: Editorials ◼ cardiopulmonary resuscitation ◼ heart arrest ◼ pediatricsDownloaded from http://ahajournals.org by on June 21, 2022de Caen and TijssenDecember 20/27, 2016 Circulation. 2016;134:2071–2073. DOI: 10.1161/CIRCULATIONAHA.116.0257232072ing specifically those children between 1 and 17 years of age. There was no difference in favorable neurologi-cal outcome in children 1 to 17 years of age who suf-fered a cardiac arrest of a primary cardiac cause, re-gardless of which CPR technique was used. Conversely, children with cardiac arrest of a noncardiac cause had better outcomes when conventional CPR was provided instead of CC-CPR (adjusted odds ratio [OR], 5.54; 95% CI, 2.52–16.99). Both studies used data from 10 years ago, before the 2010 CPR guidelines and the introduc-tion of dispatcher-assisted CPR in Japan.Fukuda et al2 studied all pediatric patients (n=2257) >1 year of age with an OHCA between 2011 and 2012. The primary outcome was favorable neurological sta-tus (cerebral performance category 1–2) at 1 month after arrest, and the predictor of interest was the type of bystander CPR provided: conventional CPR, CC-CPR, or no bystander CPR. A total of 1150 patients (53.3%) received bystander CPR, of whom 733 (63.7%) received CC-CPR. The investigators performed multivariable re-gression analyses to adjust for the imbalances found on univariate analyses. Given the limitations of regression modeling, the authors also performed propensity score matching for those patients who received bystander CPR.Any CPR compared with no CPR was associated with higher odds of neurologically favorable survival (adjust-ed OR, 5.01 [95% CI, 2.98–8.57] and 3.29 [95% CI, 1.93–5.71] for conventional and CC-CPR, respectively). In unadjusted analysis, conventional CPR was superior to CC-CPR, but there was no longer a statistically sig-nificant difference in neurologically favorable survival be-tween patients receiving either bystander conventional or CC-CPR by multivariable regression analysis (adjusted OR, 1.52; 95% CI, 0.93–2.49) and by propensity score matching (OR, 1.20; 95% CI, 0.81–1.77). There were no subgroups, including children with asphyxial cardiac arrest, in whom conventional CPR was associated with improved neurologically favorable survival compared with CC-CPR.The results of the multivariable regression model aligned well with those of the propensity score–matched model. Location of arrest (public or private) was not in-cluded in the analyses. This is particularly important for propensity score because matching assumes that both groups have the same prognosis at the time of treat-ment allocation, which would not necessarily be the case if the groups were imbalanced on this variable. In addi-tion, the authors could not specify how bystander CPR was determined, if the type of bystander CPR changed at any point, how long it was provided, or if the quality of the CPR was adequate.The Goto et al3 study describes the relationship be-tween the duration of emergency medical services (EMS)–delivered CPR for pediatric OHCA (<18 years of age) and patient outcomes using registry data between 2005 and 2012. After the exclusion of patients with un-known initial rhythm or missing time variables, 12 877 patients were included in the analysis. The authors used multivariable regression modeling with duration of CPR as a continuous variable and constructed cumulative proportion curves to determine the duration at which <1% of patients had a neurologically favorable survival.The authors found that with each additional minute of prehospital CPR by EMS, the OR for 30-day survival with cerebral performance category 1 to 2 was 0.90 (95% CI, 0.88–0.92). They found <1% survival with ce-rebral performance category 1 to 2 to be at a duration of >42 minutes, and >46 minutes if bystander CPR was provided. The stratified analyses based on initial rhythm found the duration to be >39, 42, and 46 minutes for ventricular fibrillation/pulseless ventricular tachycardia, pulseless electric activity, and asystole, respectively. No patient with prehospital CPR by EMS for >57 minutes survived with cerebral performance category 1 to 2.The main strength of the Goto et al study is the number of patients enrolled, resulting in a very strong power to detect a difference. In Japan, EMS cannot declare death (except in obvious cases, eg, rigor mortis or decapita-tion); therefore, one must use caution when comparing these results with other studies or practice settings. A number of limitations are common to both studies. As with all observational studies, the authors were unable to control for unknown confounders and other known con-founders such as in-hospital resuscitation practices and postresuscitation care, which are associated with out-comes. Furthermore, resuscitation practices may differ by jurisdiction. One striking example is that EMS use of epinephrine in Japan was <5% as a result of local regula-tions,2 whereas in North America, epinephrine was used by EMS in 68% of pediatric OHCAs.9 Last, both groups studied CPR, but neither included data on quality of CPR.What messages are we to take away from these ar-ticles? The Goto et al study helps inform management for those few patients with prolonged out-of-hospital CPR for whom it can be difficult to decide when to stop CPR in the absence of a return of spontaneous circulation. This study will no doubt be cited often in the literature and in clinical practice because it deals with an issue with which many of us struggle. It is useful to have some guidance, but in reality, the decision is more complex than this study could do justice. One must consider premorbid conditions, in-hospital resuscitation practices, various out-of-hospital resuscitation factors (which may differ in Japan), and patient/family preferences when making such an important decision.Is CC-CPR equivalent to conventional CPR for pediatric OHCA (at least for children >1 year of age), and is “doing something” (ie, CC-CPR) better than “doing nothing” (no bystander CPR)? The answer to the first question appears to be “maybe yes” and to the second question “yes or at a minimum probably yes,” at least within the Japanese Downloaded from http://ahajournals.org by on June 21, 2022Bystander Ventilation and Pediatric CPRCirculation. 2016;134:2071–2073. DOI: 10.1161/CIRCULATIONAHA.116.025723 December 20/27, 2016 2073Editorialprehospital healthcare system. One might find it intuitive that providing CC-CPR (doing something) is better than not providing any CPR (doing nothing). It is interesting to note that this was not found to be the case when analysis of the pooled data from the 2 older registry studies was performed by an ILCOR systematic review.1 The docu-mented increase in bystander CPR rates and CC-CPR in Japan in the last 10 years may be due to the more ac-cepted use of CC-CPR. In any case, this increased by-stander CPR rate has been associated with an improved neurologically favorable survival, suggesting that even for children in cardiac arrest, pushing by itself is better than doing nothing at all. We echo the authors’ call for a well-powered, prospective, randomized, controlled trial com-paring CC-CPR with conventional CPR for pediatric OHCA, although this might be a challenging study to implement. We hope that the resuscitation science community views this study as providing equipoise to support the proposal for a randomized, controlled trial.diSCloSurESNone.aFFiliatioNSFrom Pediatric Critical Care Medicine, Department of Pedi-atrics, University of Alberta, Stollery Children’s Hospital, Ed-monton, AB, Canada (A.d.C.); and Pediatric Critical Care Medi-cine, Department of Pediatrics, Western University, Children’s Hospital, London Health Sciences Centre, London, ON, Canada (J.A.T.).FootNotESCirculation is available at http://circ.ahajournals.org.rEFErENCES 1. de Caen AR, Maconochie IK, Aickin R, Atkins DL, Biarent D, Guerguerian AM, Kleinman ME, Kloeck DA, Meaney PA, Nadkar-ni VM, Ng KC, Nuthall G, Reis AG, Shimizu N, Tibballs J, Veliz Pintos R; Pediatric Basic Life Support and Pediatric Advanced Life Support Chapter Collaborators. Part 6: pediatric basic life support and pediatric advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with treatment recommendations. Circulation. 2015;132(suppl 1):S177–S203. doi: 10.1161/CIR.0000000000000275. 2. Fukuda T, Ohashi-Fukuda N, Kobayashi H, Gunshin M, Sera T, Kondo Y, Yahagi N. Conventional versus compression-only versus no-bystander cardiopulmonary resuscitation for pediatric out-of-hospital cardiac arrest. Circulation. 2016;134:2060–2070. doi: 10.1161/CIRCULATIONAHA.116.023831. 3. Goto Y, Funada A, Goto Y. Duration of prehospital cardiopulmonary resuscitation and favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide, population-based cohort study. Circulation. 2016;134:2046–2059. doi: 10.1161/CIRCULATIONAHA.116.023821. 4. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopul-monary resuscitation and emergency cardiovascular care. Circulation. 2015;132(suppl 2):S414–S435. doi: 10.1161/CIR.0000000000000259. 5. Travers AH, Perkins GD, Berg RA, Castren M, Considine J, Es-calante R, Gazmuri RJ, Koster RW, Lim SH, Nation KJ, Olasveen-gen TM, Sakamoto T, Sayre MR, Sierra A, Smyth MA, Stanton D, Vaillancourt C; Basic Life Support Chapter Collaborators. Part 3: adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with treatment rec-ommendations. Circulation. 2015;132(suppl 1):S51–S83. doi: 10.1161/CIR.0000000000000272. 6. Berg RA. Role of mouth-to-mouth rescue breathing in bystander cardiopulmonary resuscitation for asphyxial cardiac arrest. Crit Care Med. 2000;28(suppl):N193–N195. 7. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM, Berg RA, Hiraide A; Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. Conventional and chest-compression-only cardiopulmo-nary resuscitation by bystanders for children who have out-of-hos-pital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010;375:1347–1354. doi: 10.1016/S0140-6736(10)60064-5. 8. Goto Y, Maeda T, Goto Y. Impact of dispatcher-assisted by-stander cardiopulmonary resuscitation on neurological outcomes in children with out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. J Am Heart Assoc. 2014;3:e000499. doi: 10.1161/JAHA.113.000499. 9. Tijssen JA, Prince DK, Morrison LJ, Atkins DL, Austin MA, Berg R, Brown SP, Christenson J, Egan D, Fedor PJ, Fink EL, Meck-ler GD, Osmond MH, Sims KA, Hutchison JS; Resuscitation Out-comes Consortium. Time on the scene and interventions are as-sociated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015;94:1–7. doi: 10.1016/j.resuscita-tion.2015.06.012.Downloaded from http://ahajournals.org by on June 21, 2022

Is It Time to Stop Teaching Bystanders Ventilation as Part of Pediatric Cardiopulmonary Resuscitation?

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Is It Time to Stop Teaching Bystanders Ventilation as Part of Pediatric Cardiopulmonary Resuscitation?

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