Bystander Rescue Breathing CPR in Kids Tied to Better Survival

Tara Haelle

August 30, 2021

Children who receive CPR with both rescue breathing and compressions from a bystander have greater odds of survival without serious brain damage than if they receive CPR with compressions only, according to a study published online today in the Journal of the American College of Cardiology.

Specifically, a child has a 61% better chance of surviving with good neurologic outcomes if they receive compression-only CPR vs no bystander resuscitation, but that child is more than twice as likely to survive if he or she receives rescue breathing as well.

The study's clinical implications are most important for bystander CPR training, lead author Maryam Y. Naim, MD, MSCE, of the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, told Medscape Medical News.

"Many programs teach compression-only CPR to lay rescuers, and there should be a renewed emphasis on rescue breathing for the possibility a lay rescuer has to perform CPR on a child," Naim said.

That said, if a bystander is unfamiliar with how to properly administer rescue breathing or has concerns about hygiene or infection on someone they don't know, Naim advises doing compression only CPR, especially if the child older than age 1 year. "If a child is younger than a year of age please consider giving rescue breaths with chest compressions," she added.

Naim and colleagues analyzed 13,060 pediatric out-of-hospital cardiac arrests from the Cardiac Arrest Registry to Enhance Survival database, which includes data from 9-1-1 call centers, EMS providers, and receiving hospitals across 28 states. The data sample included all cases age 18 years or younger who experienced nontraumatic out-of-hospital cardiac arrest between January 2013 and December 2019, excluding those with obvious signs of death or a "do not resuscitate" order.

"Because the etiology of cardiac arrest in children is difficult to determine, especially in cases that result in death, all nontraumatic cases were included regardless of presumed etiology, including respiratory, cardiac, drowning, electrocution, or other," the authors write. The researchers defined neurologically favorable survival, the primary endpoint, as "a cerebral performance category score of 1 (no neurologic disability) or 2 (moderate disability)" at discharge. Neurologically unfavorable survival included a score of 3 (severe disability), 4 (coma or vegetative state), or death. 

Among the 10,429 cases ultimately analyzed after exclusions and missing data, 46.5% received bystander CPR. Slightly more than half of these (55.6%) received compression-only CPR while the other 45.3% received rescue breathing CPR.

Naim was surprised that compression-only CPR was the most common form of CPR given to children with cardiac arrest because the current American Heart Association/International Liaison Committee on Resuscitation recommendations note rescue breathing as the preferred form in children.

That preference exists because respiratory failure occurs more often in children than in adults as a cause of cardiac arrest, explained Sandra Weiss, MD, an interventional cardiologist and the medical director of the cardiac intensive care unit at ChristianaCare's Christiana Hospital in Newark, Delaware.

Because of that, "it's not surprising that if you give respiratory resuscitation to a child who's arresting from a respiratory cause that they're going to do better than if you just do chest compressions," said Weiss, who was not involved in the study.

The study found the most common presumed cause of arrest to be cardiac, occurring in 44.4% of cases, but it was closely followed by respiratory in nearly one third of cases (32.8%).

Infants younger than age 1 year were the most common age group to have a cardiac arrest, making up more than all other ages combined. Most out-of-hospital cardiac arrests occurred in a home and were observed by someone when they happened. While rates of bystander CPR did not change during the study's 6-year period, the incidence of compression-only CPR increased. Lay people without medical training provided the CPR in 93.6% of cases.

Only 8.6% of cardiac arrest cases resulted in neurologically favorable survival, a rate which remained steady throughout the study period. The rate increased with increasing age, at 4.6% of infants, 10.6% of children, and 16.5% of adolescents.

Those who received CPR with rescue breathing had more than double the odds of neurologically favorable survival than if they hadn't received CPR at all (adjusted odds ratio [aOR] = 2.16). Survival with a positive neurologic outcome was 1.6 times more likely with compression-only CPR than no CPR (aOR = 1.61). When researchers compared the two forms of CPR, inclusion of rescue breathing increased the child's likelihood of survival without neurologic sequelae by 36% (aOR = 1.36).

Despite these findings, however, Weiss agrees with Naim that offering compression-only CPR is preferable to offering no CPR at all.

"All resuscitation is better than no resuscitation, regardless of whether it's compression-only or respiratory breathing," Weiss told Medscape Medical News. "The average lay person is probably going to do the easiest thing, and survivability is going to be increased by doing anything rather than nothing."

Weiss also noted that it's easier to instruct people how to do chest compressions, especially, for example, during an emergency phone call with a dispatcher while waiting for EMS to arrive.

"It's absolutely imperative for people to get the basics, and the basics are compressions," she said. "That's really what is the most vital component of all resuscitative efforts, regardless of whether it's adult or pediatrics."

Weiss also acknowledge that lay people may feel particularly less comfortable administering rescue breaths to a child they don't know in the midst of the COVID-19 pandemic. Even if the odds are low that the specific child experiencing a cardiac arrest is necessarily infectious, the American Heart Association guidelines include the caveat that "if there's a concern for infection transmissibility, that compression only is acceptable," Weiss said. "It's a reality for our current state."

The superiority of rescue breathing CPR to compression-only CPR was true across all age groups, but compression-only CPR still resulted in better survival odds than no CPR at all for all age groups except infants, in whom only rescue breathing was associated with a statistically significant increased likelihood of neurologically favorable survival.

Protective factors for positive outcomes included being younger than age 1 year, the arrest being witnessed, and a having shockable rhythm. Risk factors reducing survival included being Black, being in a home, and cardiac arrests linked with AED use before EMS arrived.

The CARES program was previously funded by the CDC and is now funded by the American Red Cross, the American Heart Association, the Stryker Corporation, and Emory University. Naim was further supported by Children's Hospital of Philadelphia and the American Red Cross. The authors and Weiss have disclosed no relevant financial relationships.

J Am Coll Cardiol. Published online August 30, 2021. Abstract

Tara Haelle is a Dallas-based science and medical journalist.

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