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Multicenter Study
. 2025 Nov 3;8(11):e2544365.
doi: 10.1001/jamanetworkopen.2025.44365.

Intubation Trends and Survival in Pediatric In-Hospital Cardiac Arrest

Lindsay N Shepard  1 , Ron W Reeder  2 , Jesse Hsu  3 , Garrett Keim  1 , Robert A Berg  1 , Robert M Sutton  1 , Alexis A Topjian  1 , Nadir Yehya  1 , Ryan W Morgan  1 ; American Heart Association’s Get With The Guidelines–Resuscitation Investigators
Collaborators, Affiliations
Multicenter Study

Intubation Trends and Survival in Pediatric In-Hospital Cardiac Arrest

Lindsay N Shepard et al. JAMA Netw Open. .

Abstract

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

Objective: 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).

Design, setting, and participants: 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.

Exposure: Intra-arrest endotracheal intubation.

Main outcomes and measures: 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.

Results: 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).

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Shepard reported receiving grants from the National Institute of Child and Human Development (T32 HD060550) and nonfinancial support from an American Heart Association Early Career Investigator Award during the conduct of the study. Dr Hsu reported receiving compensation from the National Kidney Foundation for his role as Statistics/Methods Editor of the American Journal of Kidney Diseases, from the Public Library of Science for his role as a statistical advisor for PLOS One, and from the American Medical Association for his role as a statistical reviewer for JAMA Network Open. Dr Sutton reported receiving grants from the National Institutes of Health outside the submitted work. Dr Morgan reported receiving grants from National Institutes of Health, National Heart, Lung, and Blood Institute (K23HL148541) during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Selection Flow Diagram
Patient selection flow diagram indicating the number of pediatric in-hospital cardiac arrest events identified in the Get With The Guidelines—Resuscitation (GWTG-R) registry assessed for eligibility and included in the final cohort for analysis.
Figure 2.
Figure 2.. Trends in Intra-Arrest Advanced Airway Placement
Trends in intra-arrest advanced airway placement by year, showing that the percentage of patients with intra-arrest airway placement (light blue circles, left y-axis) decreased by year (nonparametric test for trend, P < .001). The dark blue circles show the median time to intubation by year (right y-axis, with the whiskers representing the IQR), which increased over the study period (nonparametric test for trend, P < .001).
Figure 3.
Figure 3.. Intra-Arrest Intubation and Association With Survival to Hospital Discharge
Unadjusted and adjusted analyses representing the association between intra-arrest intubation and survival to hospital discharge among the recent (2017-2022), historical (2000-2016), and full (2000-2022) cohorts.
See this image and copyright information in PMC

References

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