Intubation Trends and Survival in Pediatric In-Hospital Cardiac Arrest

The optimal airway management during pediatric in-hospital cardiac arrest (IHCA) is unknown.

To evaluate intubation trends during pediatric IHCA between 2000 and 2022, and determine the association of intra-arrest intubation with survival in a recent cohort of patients (2017-2022).

This retrospective cohort study (analysis performed between June 2023 and October 2024) used data from the multicenter American Heart Association Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with IHCA from 2000 through 2022 were included.

Intra-arrest endotracheal intubation.

The primary outcome was survival to hospital discharge. Intra-arrest intubation trends were assessed using nonparametric test for trend. A time-dependent propensity matched analysis assessed the association between intra-arrest intubation and hospital survival from 2017 through 2022. Each minute, patients intubated were matched with patients at risk of intubation using a propensity score, with forced matching on stratification variables and replacement of controls. Mixed-effects logistic regression assessed the association with survival outcomes, with subgroup analysis by age and illness category.

The cohort included 3262 pediatric patients with IHCA (median age, 12.0 [IQR, 3.0-83.8] months; 1775 [54.4%] male) with no advanced airway at CPR onset. Return of spontaneous circulation was attained in 2413 patients (74.0%), and 1748 (53.6%) survived to hospital discharge. The intubation rate decreased over time (33 of 39 [84.6%] in 2000 to 112 of 168 [66.7%] in 2022; P < .001). In the 2017-2022 cohort, intubation vs nonintubation in each minute of CPR was associated with decreased discharge survival odds in unadjusted analysis (odds ratio [OR], 0.18; 95% CI, 0.14-0.24; P < .001) but not after matching (adjusted OR, 1.18; 95% CI, 0.90-1.53; P = .23). In children aged 8 years or older, after matching, intubation compared with nonintubation in each minute was associated with increased odds of discharge survival (adjusted OR, 1.91; 95% CI, 1.09-3.33; P = .02).

In this cohort study of pediatric patients with IHCA between 2017 and 2022 without an advanced airway at the start of CPR, no association was identified between intra-arrest tracheal intubation and hospital survival after time-dependent propensity score matching. In subgroup analysis, intra-arrest intubation in children 8 years or older was associated with higher survival odds. These findings may have important clinical implications for clinicians caring for children with IHCA and warrant further investigation into the physiologic and practical mechanisms of this association.