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Review
. 2025 Apr 23:23:100963.
doi: 10.1016/j.resplu.2025.100963. eCollection 2025 May.

Advanced airway interventions for paediatric cardiac arrest: updated systematic review and meta-analysis

Jason Acworth  1   2 , Jimena Del Castillo  3 , Elliott Acworth  4 , Lokesh Tiwari  5 , Jesus Lopez-Herce  3 , Eric Lavonas  6   7 , Laurie Morrison  8   9 , Barnaby R Scholefield  10 ; International Liaison Committee on Resuscitation Paediatric Life Support Task Force
Affiliations
Review

Advanced airway interventions for paediatric cardiac arrest: updated systematic review and meta-analysis

Jason Acworth et al. Resusc Plus. .

Abstract

Background: Airway management is vital in paediatric resuscitation, especially since respiratory conditions are frequently the primary cause of paediatric cardiac arrest. Placement of an advanced airway device may facilitate more effective resuscitation than bag-mask ventilation but requires more skilled personnel and the time taken to perform the procedure may interfere with other vital components of resuscitation.

Objectives: To assess the use of advanced airway interventions, tracheal intubation (TI) or supraglottic airway (SGA) placement, compared with bag mask ventilation (BMV) alone for resuscitation of children in cardiac arrest.

Data sources: This was an update to a previous systematic review performed by ILCOR. A search of PubMed, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) was conducted for suitable studies published before 1 January 2025. This systematic review was registered as PROSPERO CRD42023482459.

Study eligibility: Randomised controlled trials and non-randomised comparison studies involving airway interventions (BMV, TI, SGA) in infants and children (excluding newborn infants) in cardiac arrest in any setting were included.

Study appraisal & synthesis: Investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the RoB 2 and CLARITY frameworks. Critically important outcomes included survival to hospital discharge and survival with good neurological outcome.

Results: We identified 20 suitable studies (13 from the original systematic review and 7 from the updated search), including 1 pseudorandomised clinical trial, 6 observational cohort studies using propensity matching, and 9 simple cohort studies suitable for meta-analysis. The majority of studies involved out-of-hospital cardiac arrest, with few studies exploring in-hospital cardiac arrest. The overall certainty of evidence was low to very low. For the critically important outcomes of survival to hospital discharge with good neurologic outcome and survival to hospital discharge, results showed no benefit from advanced airway interventions (TI or SGA) over BMV.

Conclusions: There is currently no supporting evidence that an advanced airway (supraglottic airway or tracheal intubation) during CPR improves survival or survival with a good neurological outcome after paediatric cardiac arrest in any setting when compared with bag-mask ventilation.Well-designed randomised trials are needed to address this important question.

Keywords: Airway; Cardiac arrest; Intubation; Paediatric; Supraglottic; Survival; Ventilation.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Barnaby R Scholefield serves on the Editorial Board of the Resuscitation Journal. He was not involved in the editorial review or the decision to publish this article.

Figures

Fig. 1
Fig. 1
PRISMA Diagram for updated systematic review.
Fig. 2
Fig. 2
Forest Plots comparing Tracheal Intubation to Bag Mask Ventilation for infants and children in cardiac arrest for the critical outcomes of Survival with Good Neurologic Function and Survival to Hospital Discharge. M−H: Cochran-Mantel-Haenszel. 95% CI: 95 percent confidence interval.
Fig. 3
Fig. 3
Forest Plots comparing Supraglottic Airway Placement to Bag Mask Ventilation for infants and children in cardiac arrest for the critical outcomes of Survival with Good Neurologic Function and Survival to Hospital Discharge. M−H: Cochran-Mantel-Haenszel. 95% CI: 95 percent confidence interval.
Fig. 4
Fig. 4
Forest Plots comparing Tracheal Intubation to Supraglottic Airway Placement for infants and children in cardiac arrest for the critical outcomes of Survival with Good Neurologic Function and Survival to Hospital Discharge. M−H: Cochran-Mantel-Haenszel. 95% CI: 95 percent confidence interval.
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