CPR With Rescue Breathing Linked to Improved Pediatric OHCA Outcomes

Child practising chest compressions on another child
Rescue breathing CPR is associated with better outcomes compared with compression-only CPR in pediatric out-of-hospital cardiac arrest.

Although compression-only cardiopulmonary resuscitation  (CO-CPR) is the most commonly administered type of bystander CPR, rescue breathing CPR (RB-CPR) is associated with better outcomes in pediatric out-of-hospital cardiac arrest. This is according to research results published in the Journal of the American College of Cardiology.1

Fewer than 10% of children survive out-of-hospital cardiac arrest, but bystander CPR has generally been associated with better rates of survival. CO-CPR appears to be as effective as rescue breathing CPR RB-CPR for adults, but may be less effective for children, who typically experience out-of-hospital cardiac arrest due to asphyxia.

Although efforts at teaching CO-CPR and improving bystander CPR rates have been made—resulting in increased survival in adult out-of-hospital cardiac arrest—the effect of these efforts on the pediatric population remain unknown.

Researchers therefore analyzed data from the Cardiac Arrest Registry to Enhance Survival (CARES) registry to test the hypothesis that RB-CPR is linked with neurologically favorable survival compared with CO-CPR in pediatric patients.

The CARES registry includes a catchment area of 145 million people in 28 U.S. states. Cardiac arrests are captured through community-level 911 centers and includes cerebral performance information.

In the current study, pediatric cases of nontraumatic out-of-hospital cardiac arrest submitted to the CARES registry between 2013 and 2019—defined as apnea and unresponsiveness that led to either CPR or defibrillation resuscitation attempts—were included. Children with obvious signs of death or do not resuscitate orders were excluded.

Investigators obtained data on age, sex, race and ethnicity, bystander witness status, arrest location, initial rhythm, automated external defibrillator (AED) use, and region of arrest. The primary study outcome was neurologically favorable survival, defined as a cerebral performance category score of 1 or 2—no or moderate disability—at the time of hospital discharge. Neurologically unfavorable survival was defined as cerebral performance category 3 or 4—severe disability or coma/vegetative state.

In total, 13,060 pediatric cardiac arrests were identified in the CARES database, of whom 46.5% received bystander CPR. After exclusions were applied, 10,429 cardiac arrests were evaluated. Within this group, 55.6% received CO-CPR and 45.3% received RB-CPR. Presumed arrest etiology was respiratory, drowning, drug overdose, electrocution, and exsanguination in 44.4%, 32.8%, 8.8%, 1.8%, 0.2%, and 0.2% of cases, respectively.

Cardiac arrest was more common in infants, boys, and both Black and White children. The majority took place in a home or residence without a shockable rhythm and no AED use prior to EMS arrival.

Over the 6-year study period, rates of bystander CPR did not change. Bystander CPR was most commonly performed by a lay family member, a lay person, or a lay person with medical training (71.7%, 21.9%, and 6.4%, respectively). However, there was a significant increase identified by investigators in the proportion of pediatric cardiac arrests that received CO-CPR.

Lay family members and lay persons were both more likely to perform CO-CPR—54.8% and 58.9%, respectively—while lay persons with medical training were more likely to perform RB-CPR (61.5%).

Researchers found that 8.6% of cardiac arrests led to neurologically favorable outcomes. Over the study period, there was no change in this rate. In analyses unadjusted for demographic and clinical characteristics, arrests with either RB- or CO-CPR had better outcomes vs no CPR (13.4% and 12.2% vs 5.8%).

Results of a multivariable analysis showed that RB-CPR and CO-CPR were both independently associated with neurologically favorable survival vs no CPR (adjusted odds ratios [aORs] for RB-CPR and CO-CPR, 2.16 and 1.61, respectively). In a separate model excluding those who did not receive CPR, investigators found that RB-CPR was associated with higher odds of neurologically favorable survival vs CO-CPR (aOR, 1.36).

By age group, neurologically favorable survival was most common in adolescents (16.5% vs 10.6% of children and 4.6% of infants). In infants and children, RB-CPR was more frequently associated with neurologically favorable survival (6.9% vs 5.2% and 17.3% vs 13.9%). In adolescents, the data were similar, showing neurologically favorable survival in 25.7% of those who received RB-CPR vs 23.7% with CO-CPR.

Study limitations include the observational nature of the data, lack of type of bystander CPR for all arrests, and no information on dispatcher instruction, CPR quality, or lay rescuer training, as well as possible post-cardiac arrest in-hospital confounders.

“These results,” the study authors concluded, “support the present [American Heart Association] guidelines with RB-CPR as the preferred modality for pediatric [out-of-hospital cardiac arrest].”

In an editorial comment, Gene Yong-Kwang Ong, MBBS, of the Department of Emergency Medicine at KK Women’s and Children’s Hospital in Singapore and the Duke-NUS Medical School in Singapore, noted that this study adds “important data to the limited published pediatric data on the topic,”2 with many important observations made. The results of the study have important implications, particularly in light of the COVID-19 pandemic.

“The perceived reluctance to provide ventilation for adult cardiac arrest victims was partially attributed to concerns about hygiene and [the] potential for infections,” he wrote. “These considerations during the provision of lifesaving measures to a young family member may not be quite the same for adult cardiac arrest victims. Even during the ongoing COVID-19 pandemic, the risk of rescuers acquiring COVID-19 through [the] provision of rescue breaths may be more readily accepted compared with adults, as pediatric cardiac arrest victims are likely to be family members.”


  1. Naim MY, Griffis HM, Berg RA, et al. Compression-only versus rescue-breathing cardiopulmonary resuscitation after pediatric out-of-hospital cardiac arrest. J Am Coll Cardiol. Published online August 30, 2021. doi:10.1016/j.jacc.2021.06.042
  2. Ong GY-K. Chest compression-only cardiopulmonary recuscitation in pediatric out-of-hospital cardiac arrest: (Don’t) take my breath away. J Am Coll Cardiol. Published online August 30, 2021. doi:10.1016/j.jacc.2021.07.029