Author: Dr. Jeny Tan-Creevy


Pediatric out-of-hospital cardiac arrest (OHCA) is a major public health problem and survival rates are very low suggesting that pediatric OHCA care needs improvement.

Evidence for effectiveness of prehospital advanced airway management (AAM) in OHCA is limited and warrants further study.

Goal of the Study:

To evaluate the association between prehospital advanced airway management and patient outcomes after pediatric out-of-hospital cardiac arrest using time-dependent propensity score and risk-set matching.


  • The study took place between January 2014 to December 2016.
  • Data was collected from an All-Japan Utstein Registry (OHCA registry).
  • During this period, there were 4834 Pediatric out-of-hospital cardiac arrests. Amongst this cohort, 3801 participants were included and 1033 were excluded. Please refer below for the inclusion/exclusion criteria.


  • For the purposes of this study, cardiac arrest is defined as the “lack of cardiac mechanical activity confirmed by lack of clinical evidence of circulation.”
  • The study evaluates Emergency Medical Services (EMS), which in this case is composed of a 3-member crew, including at least 1 emergency life-saving technician (ELST). An ELST can place supraglottic airway (SGA). Some obtain further certification and are able to perform endotracheal intubation (ETI)
  • Resuscitation includes an external shock delivery by EMS or layperson, or chest compressions performed by EMS.


Inclusion Criteria

  • Pediatric patients (<18 years old) with traumatic and non-traumatic OHCA on whom EMS attempted to resuscitate.

Exclusion Criteria

  • MS-witnessed arrest
  • OHCA without ELST involvement
  • OHCA with unknown initial rhythm
  • OHCA with unknown values in resuscitation interval variables
    • Ex: initiation of CPR, AAM, shock delivery, etc.
  • OHCA with interval between emergency call to initiation of EMS CPR that is greater than 30 mins.


Primary Outcome

  • One month survivability

Secondary Outcome

  • One month survival with favorable functional status [using the Cerebral Performance Category (CPC) score].


Using time-dependent propensity score and matching cohorts, the overall, the primary outcome (one-month survival rate) of patients with an out-of-hospital cardiac arrest who did not received a prehospital advanced airway is 9.6% and those who received a prehospital advanced airway is 11.4%.

The secondary outcome of one month survival with a favorable functional status in those who did not receive a prehospital advanced airway is 2.2% in comparison to only 2.0 % in those who did.

Please refer to the table for a further stratified analysis.


There is no significant difference in 1-month survival nor favorable functional status between those who received prehospital advanced airway management to those who did not.

Strengths of the article includes avoiding resuscitation time bias by accounting for timing of AAM, avoiding selection bias by using time-dependent propensity score, and matching cohorts.

There are also limitations to the article. For example, we have no data as to how failed AAM is reported. These may have been counted as No AAM therefore confounding the results. Unmeasured confounders like patient comorbidities, quality of CPR, ELST level of training, etc. are not recorded. Also, the Pediatric Cerebral Performance Category to assess neurological functionality was not available and therefore the Adult Cerebral Performance Category was adapted for assess secondary outcomes.

Findings support the current American Heart Association (AHA) guidelines: “in the prehospital setting, it is reasonable to ventilate and oxygenate infants and children with a bag-mask device, especially if transport time is short.”


  • A Okubo M, Komukai S, Izawa J, et al. Prehospital advanced airway management for paediatric patients with out-of-hospital cardiac arrest: A nationwide cohort study. Resuscitation. 2019;145:175-184. doi:10.1016/j.resuscitation.2019.09.007
  • Part 10: Pediatric Advanced Life Support. Circulation. Published August 22, 2000. Accessed December 9, 2020.

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