Objective: to determine whether tracheal intubation of paediatric patients after in-hospital cardiac arrest is associated with better outcomes.
Design: prospective observational cohort study.
Setting: data from United States hospitals included in the Get With The Guidelines-Resuscitation Registry.
Population under study: the registry collected data for paediatric patients aged less than 18 years with a history of in-hospital cardiac arrest between January 2000 and December 2014. Cardiac arrest was defined as a minute or more of chest compressions. Of 15 811 potential cases of arrest identified, 2294 were finally included (1555 intubated and 739 not intubated). Another 537 patients were excluded from the main analysis due to missing or inconsistent data but were included in a subsequent sensitivity analysis. In addition to these patients, patients who were receiving assisted ventilation and/or had an invasive airway in place at the time chest compressions were initiated were excluded. Furthermore, cardiac arrests in the delivery room or Neonatal Intensive Care Unit were also excluded.
Assessment of prognostic factor: index intubation (insertion of a tracheal tube during the cardiac arrest event) and time to intubation (in whole minutes) from the start of chest compressions to when the tracheal tube was correctly inserted.
Outcome measurement: the primary outcome was percent survival at the time of hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and favourable neurologic outcome at discharge (assessed by means of the Pediatric Cerebral Performance Category [PCPC] score). The authors performed unadjusted and adjusted analyses. The adjusted association between intubation and the primary and secondary outcomes was assessed by means of the propensity score, calculated using a multivariable Cox proportional hazards model. The adjusted analysis included various variables with a potential association with the event based on the findings of similar studies conducted in the past. Matching was performed 1:1. Three different sensitivity analyses and two subgroup analyses were performed.
Main results: the patients were young children (median age, 7 months; interquartile range, 21 days to 4 years of age). The main adjusted analysis showed that survival was lower in the intubated group (36%) than in the not-intubated group (41%), with an intubation-attributable proportion of decreased survival of 6.2% (95% confidence interval [95 IC], 2.8 to 9.4)*. There were no differences between groups in the two secondary outcomes. The sensitivity and subgroup analyses confirmed the trends observed in the results except in one subgroup of patients documented as pulseless at any time, with a survival of 30% in those intubated versus 34% in those not intubated (intubation-attributable proportion: 2.9%; 95 CI, -0.4 to 6.1).
Conclusion: among paediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiopulmonary resuscitation was associated with decreased survival. Although the study design did not eliminate all potential for confounding, these findings do not support the current emphasis on early tracheal intubation during resuscitation in these patients.
Conflicts of interest: one of the authors reported serving as a paid consultant for the American Heart Association. No other authors reported disclosures.
Funding source: not noted.