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G Model
ARTICLE IN PRESS
RESUS-7347; No. of Pages 9
Resuscitation xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Conventional versus chest-compression-only cardiopulmonary
resuscitation by bystanders for children with out-of-hospital cardiac
arrest夽
Yoshikazu Goto a,∗ , Akira Funada a , Yumiko Goto b
a
b
Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
Department of Cardiology, Yawata Medical Centre, Komatsu, Japan
a r t i c l e
i n f o
Article history:
Received 19 July 2017
Received in revised form 11 October 2017
Accepted 18 October 2017
Keywords:
Out-of-hospital cardiac arrest
Cardiopulmonary resuscitation
Children
Infant
Epidemiology
a b s t r a c t
Aim: It is unclear whether chest-compression-only cardiopulmonary resuscitation (CC-CPR) is therapeutically equivalent to conventional CPR for children with out-of-hospital cardiac arrest (OHCA). We aimed
to determine the association of CC-CPR and conventional CPR with outcomes in discrete child patient
populations with OHCA.
Methods: We analysed 6810 children (aged <18 years) using Japanese registry from 2007 to 2014. Main
outcomes measure was 30-day neurologically intact survival after OHCA, defined as Glasgow-Pittsburgh
cerebral performance categories 1 or 2.
Results: In propensity score-matched children aged 1–17 years (n = 2682), overall neurologically intact
survival rate was significantly higher after conventional CPR than after CC-CPR (9.4% vs. 6.0%, P = 0.001).
However, there was no significant difference between the two CPR modalities in patients with cardiac
aetiology (14.2% vs. 11.8%, P = 0.32), initial shockable rhythm (35.3% vs. 31.7%, P = 0.59), or age ≥8 years
(12.4% vs. 9.8%, P = 0.13). For matched infants (n = 1994), no significant differences were observed in overall neurological intact survival between conventional CPR and CC-CPR (2.2% vs. 1.3%, P = 0.17). In infant
subgroup analyses, neurologically intact survival was similar between the CPR modalities for cardiac
aetiology (0.3% vs. 1.0%; P = 0.37) and for witnessed arrest (6.2% vs. 6.0%; P = 0.98).
Conclusions: In the majority of the paediatric subgroups, conventional CPR was associated with improved
outcomes compared to CC-CPR. CC-CPR was associated with 30-day neurologically intact survival similar
to conventional CPR for children with OHCA aged ≥8 years, for children aged 1–17 years with cardiac
aetiology or initial shockable rhythm, and for infants with cardiac aetiology or witnessed arrest.
© 2017 Elsevier B.V. All rights reserved.
1 Introduction
Early bystander cardiopulmonary resuscitation (CPR) for outof-hospital cardiac arrest (OHCA) is crucial in the chain of survival
[1–5]. Fortunately, the bystander CPR rate in children has increased
recently from ∼30% [6,7] to ∼50% [8–12]. In order to increase
bystander CPR, in 2008, the American Heart Association (AHA) recommended chest-compression-only CPR (CC-CPR) for adults with
OHCA [13]. However, CC-CPR for cardiac arrest does not apply to
patients with non-cardiac origin, unwitnessed arrest, or children.
夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://10.1016/j.resuscitation.2017.10.015.
∗ Corresponding author at: Kanazawa University Hospital, Department of Emergency and Critical Care Medicine, Takaramachi 13-1, Kanazawa 920-8640, Japan,
E-mail address: gotoyosh@med.kanazawa-u.ac.jp (Y. Goto).
Specifically, two investigations of children with OHCA demonstrated that receiving CC-CPR was associated with inferior 30-day
intact neurological survival rates compared with conventional CPR
(chest compressions with rescue breaths) [14,15]. However, in children aged 1–17 years with presumed cardiac aetiology, CC-CPR was
equally associated with 30-day neurologically intact survival compared with conventional CPR [14]. Based on these findings, in 2015,
the International Liaison Committee On Resuscitation (ILCOR) [5]
recommended that rescuers provide conventional CPR for infants
and children in cardiac arrest; if rescuers could not provide rescue
breaths, they should perform CC-CPR. Recent evidence from Japan
[16] shows that CC-CPR for children is associated with improved
30-day neurologically intact survival compared with no bystander
CPR; no statistically significant differences were observed for CCCPR compared with conventional CPR regardless of arrest aetiology,
witness status, or age subgroups. We hypothesized that CC-CPR
by bystanders produces neurologically intact survival equivalent
https://doi.org/10.1016/j.resuscitation.2017.10.015
0300-9572/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
G Model
RESUS-7347; No. of Pages 9
ARTICLE IN PRESS
Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
2
to conventional CPR for children with OHCA aged ≥8 years and
for children aged <8 years with presumed cardiac origin or initial
shockable rhythm.
Using propensity-score matching analyses, the present study
investigated a large cohort of paediatric OHCAs to assess differences in post-OHCA outcomes between CC-CPR and conventional
CPR according to age.
2 Methods
2.1 Study design
This was a nationwide, population-based, observational study
of all children (aged <18 years) receiving resuscitation performed
by emergency medical services (EMS) personnel after OHCA in
Japan between January 1, 2007, and December 31, 2014. Cessation of cardiac mechanical activity was confirmed by the absence
of signs of circulation, indicating cardiac arrest [17]. As determined
by the attending physicians and EMS personnel, the cause of arrest
was presumed to be cardiac unless there was evidence to suggest
trauma, hanging, drowning, drug overdose, asphyxia, respiratory
disease, cerebrovascular disease, malignant tumours, or any other
non-cardiac aetiology. This study was conducted with the approval
of the ethics committee at Kanazawa University.
2.2 Study setting
Japan has nearly 127 million residents in an area of 378,000 km2 .
The Fire and Disaster Management Agency (FDMA) of Japan supervises the nationwide EMS system, while the local fire stations
operate the local EMS systems. EMS personnel are trained and permitted to use several resuscitative methods, including automated
external defibrillators, insertion of an airway adjunct, insertion of
a peripheral intravenous line, and administration of Ringers lactate solution. Further, certain emergency personnel are permitted
to insert a tracheal tube and administer intravenous epinephrine.
Importantly, Japanese law prohibits EMS personnel from terminating resuscitation in the field. Accordingly, most patients with OHCA
undergo CPR by EMS providers and are subsequently transported to
hospitals. Emergency telephone dispatchers in Japan are required
to provide CPR instructions for CC-CPR if it is difficult for them to
administer rescue breathing since 2006 [18].
2.3 Data collection and quality control
Since 2005, The FDMA in Japan has launched an on-going,
prospective, population-based, observational study involving all
OHCA patients receiving EMS treatment [17]. Specifically, EMS personnel at each treatment centre recorded patient data using an
Utstein-style template in cooperation with the physician in charge.
The recorded data were then transferred to individual local fire
stations and subsequently integrated into the data registry system on the FDMA database. Ultimately, all data were stored in
the nationwide database developed by the FDMA for public use.
With permission from the FDMA, we analysed de-identified patient
data contained within this database for the present investigation. Neurological outcomes were stratified utilizing the Cerebral
Performance Category (CPC) scale (category 1: good cerebral performance; category 2: moderate cerebral disability; category 3:
severe cerebral disability; category 4: coma or vegetative state;
and category 5: death) [19]. For all patients, CPC categorization was
determined by the attending physician.
2.4 Study endpoints
Primary endpoints included 30-day neurologically intact survival, defined as a CPC of 1 or 2 and 30-day survival.
2.5 Statistical analysis
We compared 30-day outcomes between conventional CPR
and CC-CPR, categorizing patients into two age groups: <1 year
(infants) or 1–17 years. To perform rigorous adjustments for differences in the baseline characteristics of patients, we utilized
both logistic regression analyses for unmatched patients as well
as propensity-score matching analyses to adjust for selection bias
when comparing outcomes between conventional CPR and CC-CPR.
In analyses of unmatched cohorts, both univariate and multivariate logistic regression analyses were performed in order
to estimate the association between patient outcome and the
type of bystander CPR performed. In propensity-score matching
analyses, we estimated two propensity scores by fitting a logisticregression model that includes 17 variables for infants and 18
variables for patients aged 1–17 years as described in Table 1.
We performed one-to-one nearest-neighbour matching between
patients with conventional CPR and CC-CPR without replacement,
using a caliper width equal to 0.20 of the standard deviation of
the logit of the propensity score [20]. Before analysing outcomes,
we assessed the success of the propensity-matching procedure
by comparing the distribution of patient characteristics in the
matched sample by calculating an absolute standardized difference
[21]. An absolute standardized difference greater than or equal to
0.1 was considered indicative of a significant imbalance between
the two cohorts [22]. To compare the 30-day outcomes between
bystander CPR modality, we utilized either chi-squared or Fishers
exact tests and further analysed subgroups according to aetiology
(cardiac/non-cardiac), initial rhythm (shockable/non-shockable),
witnessed status (yes/no), age (1–7 years/8–17 years).
Continuous variables are expressed as the mean ± standard
deviation, while categorical variables are expressed as percentages. As an estimate of effect size and variability, we reported odds
ratio (OR) with 95% confidence intervals (CIs). All statistical analyses were performed using the JMP statistical package (Version 13,
SAS Institute Inc., Cary, NC, USA). All reported tests were two-tailed
with a P-value <0.05 considered statistically significant.
3 Results
Over the 8 years, data for 967,683 patients were compiled in
the database. Of these cases, 1.3% of patients (n = 12,708) were
treated by EMS personnel and were eligible for study enrolment
(Fig. 1). Excluding patients with public access defibrillation-only
CPR, rescue breathing-only CPR, and no bystander CPR, we analysed 2842 infants and 3968 children aged 1–17 years with OHCA.
In infants, 1994 of the 2842 patients with bystander CPR (70.2%)
were matched as described. Further, in children aged 1–17 years,
patient matching was achieved for 2682 of 3968 patients with
bystander CPR (67.6%). Absolute standardized differences in the
matched cohorts were considerably improved in each age cohort
(Tables 1 and 2). Regardless of age, the proportions of patients
receiving bystander CPR and CC-CPR significantly increased during the study (all Ptrend < 0.001, Supplementary Tables S1 and S2).
Further, 30-day survival for infants was significantly increased over
the study period (Ptrend < 0.01, Supplementary Table S1). However,
the proportions of 30-day CPC 1–2 for both age groups did not
significantly increase (Supplementary Tables S1 and S2).
Table 3 describes the results of the logistic regression analyses in the unmatched cohorts by age. Between age groups, the
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
Age 1–17 years (n = 3968)
Conventional CPR
Compression-only CPR
(n = 1191)
(n = 1651)
1
ASD
Conventional CPR
Compression-only CPR
(n = 1496)
(n = 2472)
ASD1
242
245
156
144
114
126
76
88
(20.3)
(20.6)
(13.1)
(12.1)
(9.6)
(10.6)
(6.4)
(7.4)
192
251
169
178
201
199
228
233
(11.6)
(15.2)
(10.2)
(10.8)
(12.2)
(12.1)
(13.8)
(14.1)
0.241
0.141
0.09
0.04
0.08
0.05
0.251
0.221
241
251
203
216
165
158
118
144
(16.1)
(16.8)
(13.6)
(14.4)
(11.0)
(10.6)
(7.9)
(9.6)
221
221
272
311
351
336
389
371
(8.9)
(8.9)
(11.0)
(12.6)
(14.2)
(13.6)
(15.7)
(15.0)
0.221
0.241
0.08
0.05
0.09
0.09
0.241
0.161
36
77
397
144
234
93
210
NA
671
(3.0)
(6.5)
(33.3)
(12.1)
(19.7)
(7.8)
(17.6)
(4.4)
(5.6)
(40.2)
(17.1)
(11.4)
(7.9)
(13.5)
(56.3)
73
92
663
282
188
130
223
NA
971
(58.8)
0.07
0.04
0.141
0.141
0.231
<0.01
0.111
NA
0.05
51
121
447
206
278
149
244
8
924
(3.4)
(8.3)
(29.9)
(13.8)
(18.6)
(10.0)
(16.3)
(5.9)
(61.8)
92
204
843
409
390
206
328
9.2
1540
(3.7)
(8.3)
(34.1)
(16.6)
(15.8)
(8.4)
(13.3)
(5.9)
(62.3)
0.02
0.01
0.09
0.08
0.07
0.06
0.09
0.211
0.01
474
717
(39.8)
(60.2)
710
941
(43.0)
(57.0)
0.07
0.07
500
996
(33.4)
(66.6)
733
1739
(29.7)
(70.3)
0.08
0.08
32
1159
(2.7)
(97.3)
40
1611
(2.4)
(97.6)
0.02
0.02
148
1348
(9.9)
(90.1)
168
2304
(6.8)
(93.2)
0.111
0.111
976
148
67
(81.9)
(12.4)
(5.6)
1388
227
36
(84.1)
(13.7)
(2.2)
0.06
0.04
0.181
950
300
246
(63.5)
(20.1)
(16.4)
1697
464
311
(68.6)
(18.8)
(12.6)
0.111
0.03
0.111
910
1
(76.4)
(0.1)
1389
0
(84.1)
(0)
0.201
NA
1006
90
(67.3)
(2.2)
1853
55
(75.0)
(6.0)
0.171
0.191
1160
209
181
12
117
29
11
7.4
26.0
(97.4)
(17.6)
(15.2)
(1.0)
(9.8)
(2.4)
(0.9)
(3.9)
(9.9)
1602
269
242
30
153
48
18
7.4
26.8
(97.0)
(16.3)
(14.7)
(1.8)
(9.3)
(2.9)
(1.1)
(3.1)
(9.3)
0.02
0.03
0.02
0.07
0.02
0.03
0.02
0.01
0.09
1448
301
275
182
286
172
72
7.8
28.8
(96.8)
(20.1)
(18.4)
(12.2)
(19.1)
(11.5)
(4.8)
(3.8)
(10.1)
2393
407
371
215
546
272
112
7.5
29.4
(96.8)
(16.5)
(15.0)
(8.7)
(22.1)
(11.0)
(4.5)
(3.3)
(10.4)
<0.01
0.09
0.09
0.111
0.07
0.02
0.01
0.08
0.05
Values are reported as n (%) unless indicated otherwise. AED, automated external defibrillator; ASD, absolute standardized difference; CPR, cardiopulmonary resuscitation; NA, not available; SD, standard deviation.
1
An ASD of equal or more than 0.1 was considered to indicate a substantial imbalance between the two cohorts.
†
Numbers of patients with missing data were 6 (0.21%) in the aged <1 year cohort and 6 (0.15%) in the aged 1–17 years cohort.
‡
Numbers of patients with missing data were 8 (0.28%) in the aged <1 year cohort and 10 (0.25%) in the aged 1–17 years cohort.
ARTICLE IN PRESS
Year
2007
2008
2009
2010
2011
2012
2013
2014
Geographic Japanese regions
North (Hokkaido)
Northeast (Tohoku)
East (Kanto-Koshinetsu)
Central (Chubu-Hokuriku)
Midwest (Kinki)
West (Chugoku-Shikoku)
South (Kyushu-Okinawa)
Age, y, mean (SD)
Male sex
Aetiology of cardiac arrest
Presumed cardiac
Non-cardiac
Initial cardiac rhythm
Ventricular fibrillation or tachycardia
Pulseless electrical activity/asystole
Bystander witnessed status
No witness
Family member
Nonfamily member
Dispatcher CPR instruction
Offered
Use of public access AED by bystander
CPR by emergency responder
Emergency lifesaving technician present in ambulance
Physician present in ambulance
Prehospital advanced medication by attended physician
Defibrillation by emergency responder
Use of advanced airway management
Insertion of intravenous line
Epinephrine administration
Call-to-response time, min, mean (SD)†
Call-to-hospital arrival time, min, mean (SD)‡
Age <1 year (n = 2842)
G Model
RESUS-7347; No. of Pages 9
Characteristic
Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
Table 1
Baseline Characteristics of Unmatched Patients according to Age.
3
Conventional CPR
Compression-only CPR
(n = 997)
(n = 997)
ASD1
Conventional CPR
Compression-only CPR
(n = 1341)
(n = 1341)
ASD1
(17.0)
(19.7)
(12.0)
(12.3)
(10.8)
(11.6)
(7.6)
(8.7)
172
190
120
121
100
106
96
92
(17.2)
(19.0)
(12.0)
(12.1)
(10.0)
(10.6)
(9.6)
(9.2)
0.01
0.02
<0.01
0.01
0.03
0.03
0.07
0.02
194
194
180
199
163
153
117
141
(14.5)
(14.5)
(13.4)
(14.8)
(12.2)
(11.4)
(8.7)
(10.5)
186
199
186
196
174
149
119
132
(13.9)
(14.8)
(13.9)
(14.6)
(13.0)
(11.1)
(8.9)
(9.8)
0.02
0.01
0.01
0.01
0.02
0.01
0.01
0.02
32
64
363
136
155
80
167
NA
564
(3.2)
(6.4)
(36.3)
(13.6)
(15.5)
(8.0)
(16.7)
(2.4)
(6.9)
(36.5)
(12.8)
(15.8)
(7.8)
(17.6)
(56.5)
24
69
364
128
158
78
176
NA
564
(56.5)
0.05
0.02
<0.01
0.02
0.01
0.01
0.02
NA
0
48
115
411
193
244
124
206
8.1
829
(3.6)
(8.6)
(30.7)
(14.4)
(18.2)
(9.3)
(15.4)
(5.9)
(61.8)
51
106
422
199
229
118
216
7.9
828
(3.8)
(7.9)
(31.5)
(14.8)
(17.1)
(8.8)
(16.1)
(5.8)
(61.7)
0.01
0.02
0.02
0.01
0.03
0.02
0.02
0.02
<0.01
399
598
(40.0)
(60.0)
416
581
(41.7)
(58.3)
0.03
0.03
437
904
(32.6)
(67.4)
450
891
(33.6)
(66.4)
0.02
0.02
28
969
(2.8)
(97.2)
25
972
(2.5)
(97.5)
0.02
0.02
119
1222
(8.9)
(91.1)
120
1221
(9.0)
(91.0)
<0.01
<0.01
835
127
35
(83.8)
(12.7)
(3.5)
833
130
34
(83.6)
(13.0)
(3.4)
0.01
0.01
0.01
871
270
200
(65.0)
(20.1)
(14.9)
870
278
193
(64.9)
(20.7)
(14.4)
<0.01
0.01
0.01
792
0
(79.4)
(0)
783
0
(78.5)
(0)
0.02
NA
937
55
(69.9)
(4.1)
943
49
(70.0)
(3.7)
0.01
0.02
975
172
151
12
98
25
8
7.3
26.1
(97.8)
(17.2)
(15.1)
(1.2)
(9.8)
(2.5)
(0.8)
(3.2)
(9.6)
966
163
150
12
96
24
9
7.3
26.4
(96.9)
(16.3)
(15.0)
(1.2)
(9.6)
(2.4)
(0.9)
(3.2)
(9.7)
0.06
0.02
<0.01
0
0.01
0.01
0.01
0.01
0.03
1297
260
236
147
263
155
60
7.70
28.9
(96.7)
(19.4)
(17.6)
(11.0)
(19.6)
(11.6)
(4.5)
(3.7)
(10.2)
1291
248
232
143
259
123
56
7.70
28.9
(96.3)
(18.5)
(17.3)
(10.7)
(19.3)
(9.2)
(4.2)
(3.6)
(10.5)
0.02
0.02
0.01
0.01
0.01
0.08
0.01
0.01
<0.01
Values are reported as n (%) unless indicated otherwise. AED, automated external defibrillator; ASD, absolute standardized difference; CPR, cardiopulmonary resuscitation; NA, not available; SD, standard deviation.
1
An ASD of equal or more than 0.1 was considered to indicate a substantial imbalance between the two cohorts.
ARTICLE IN PRESS
170
197
120
123
108
116
76
87
Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
Year
2007
2008
2009
2010
2011
2012
2013
2014
Geographic Japanese regions
North (Hokkaido)
Northeast (Tohoku)
East (Kanto-Koshinetsu)
Central (Chubu-Hokuriku)
Midwest (Kinki)
West (Chugoku-Shikoku)
South (Kyushu-Okinawa)
Age, y, mean (SD)
Male sex
Aetiology of cardiac arrest
Presumed cardiac
Non-cardiac
Initial cardiac rhythm
Ventricular fibrillation or tachycardia
Pulseless electrical activity/asystole
Bystander witnessed status
No witness
Family member
Nonfamily member
Dispatcher CPR instruction
Offered
Use of public access AED by bystander
CPR by emergency responder
Emergency lifesaving technician present in ambulance
Physician present in ambulance
Prehospital advanced medication by attended physician
Defibrillation by emergency responder
Use of advanced airway management
Insertion of intravenous line
Epinephrine administration
Call-to-response time, min, mean (SD)
Call-to-hospital arrival time, min, mean (SD)
Age 1–17 years (n = 2682)
Age <1 year (n = 1994)
G Model
Characteristic
RESUS-7347; No. of Pages 9
4
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
Table 2
Baseline Characteristics of Matched Patients according to Age.
G Model
RESUS-7347; No. of Pages 9
ARTICLE IN PRESS
Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
Fig. 1. Flowchart of Patient Inclusion Criteria.
5
CPR, cardiopulmonary resuscitation; EMS, emergency medical services.
proportions of 30-day survival and 30-day CPC 1 or 2 were significantly reduced after CC-CPR than after conventional CPR, described
as follows (CC-CPR vs. conventional CPR): for infants, survival:
6.8% (112/1651) vs. 9.7% (115/1191) [adjusted OR, 0.66; 95% CI,
0.49–0.89]; CPC 1 or 2: 1.3% (21/1651) vs. 2.4% (29/1191) [adjusted
OR, 0.51; 95% CI, 0.27–0.95]; for children aged 1–17 years, survival: 12.1% (300/2472) vs. 19.4% (290/1496) [adjusted OR, 0.61;
95% CI, 0.50–0.74]; CPC 1 or 2: 5.0% (123/2472) vs. 10.0% (149/1496)
[adjusted OR, 0.50; 95% CI, 0.37–0.67].
Fig. 2 shows the matched patient numbers and 30-day outcomes by year. In infants, no significant differences were found in
the two types of bystander CPR for every 2-year period. In children aged 1–17 years, 30-day CPC 1–2 after conventional CPR was
significantly higher than that after CC-CPR in the 2007–2008 and
2009–2010 periods, but not in the 2011–2012 and 2013–2014 periods. The P-value for trend in 30-day CPC 1–2 was found to be
significant only in CC-CPR for children aged 1–17 years (P = 0.02).
Fig. 3 shows the results of outcome comparisons between conventional CPR and CC-CPR following propensity-score matching
by age. Among infants, no significant differences were observed
between the two types of bystander CPR with respect to overall
30-day outcomes. When stratified into subgroups, the proportion
of 30-day CPC 1–2 was significantly higher after conventional CPR
than after CC-CPR in infants with non-cardiac origin (3.5% [21/598]
vs. 1.5% [9/581]; P = 0.04) and unwitnessed (1.4% [12/835] vs. 0.4%
[3/833]; P = 0.03). However, no significant difference was observed
in 30-day CPC 1–2 in patients with cardiac origin and with witnessed arrest. When stratified by initial rhythm, no significant
differences were identified between either bystander CPR modality for infants with respect to 30-day outcomes. Of the patients
aged 1–17 years, the proportions of overall 30-day survival and
30-day CPC 1 or 2 were significantly higher after conventional CPR
than after CC-CPR (survival: 18.6% [250/1341] vs. 12.7% [170/1341];
P < 0.001; CPC 1–2: 9.4% [126/1341] vs. 6.0% [80/1341]; P = 0.001).
When stratified into subgroups, proportions of 30-day favourable
outcomes were similar for children with cardiac origin and initial
shockable rhythm. When stratified by age subgroup, the proportion
of 30-day survival was significantly higher after conventional CPR
than after CC-CPR for patients aged 8–17 years (20.2% [132/652] vs.
15.8% [102/646], P = 0.04). However, the observed differences were
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
G Model
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6
Table 3
Comparison of Outcomes in the Unmatched Cohorts by Age.
Age <1 year
Total no. of unmatched patients
30-day survival, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted§ , OR (95% CI)
30-day CPC 1 or 2, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted§, OR (95% CI)
Age 1–17 years
Total no. of unmatched patients
30-day survival, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
30-day CPC 1 or 2, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
Patients aged 1–7 years, n
30-day survival, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
30-day CPC 1 or 2, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
Patients aged 8–17 years, n
30-day survival, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
30-day CPC 1 or 2, n/total n (%)
Unadjusted, OR (95% CI)
Adjusted¶ , OR (95% CI)
Overall unmatched patients
Conventional CPR
2842
227/2842
(8.0)
50/2842
(1.8)
1191
115/1191
Reference
Reference
29/1191
Reference
Reference
3968
590/3968
(14.9)
272/3968
(6.9)
1816
236/1816
(13.0)
71/1816
(3.9)
2152
354/2152
(16.5)
201/2152
(9.3)
1496
290/1496
Reference
Reference
149/1496
Reference
Reference
781
133/781
Reference
Reference
49/781
Reference
Reference
715
157/715
Reference
Reference
100/715
Reference
Reference
Compression-only CPR
(9.7)
(2.4)
(19.4)
(10.0)
(17.0)
(6.3)
(22.0)
(14.0)
1651
112/1651
0.68
0.66
21/1651
0.52
0.51
2472
300/2472
0.57
0.61
123/2472
0.47
0.50
1035
103/1035
0.54
0.52
22/1035
0.32
0.27
1437
197/1437
0.56
0.72
101/1437
0.46
0.68
(6.8)
(0.52–0.89)†
(0.49–0.89)†
(1.3)
(0.29–0.91)*
(0.27–0.95)*
(12.1)
(0.48–0.68)‡
(0.50–0.74)‡
(5.0)
(0.37–0.61)‡
(0.37–0.67)‡
(10.0)
(0.41–0.71)‡
(0.38–0.69)‡
(2.1)
(0.19–0.54)‡
(0.16–0.46)‡
(13.7)
(0.45–0.71)‡
(0.55–0.94)*
(7.0)
(0.35–0.62)‡
(0.47–0.97)‡
Values are reported as n/total n (%) unless indicated otherwise. CI, confidence interval; CPC, cerebral performance category; CPR, cardiopulmonary resuscitation; OR, odds
ratio.
*
p < 0.05.
†
p < 0.01.
‡
p < 0.001.
§
Adjusted for a predefined set of potential 11 confounders: aetiology of cardiac arrest, initial cardiac rhythm, bystander witness status, sex, geographic Japanese regions,
year, prehospital advanced medication by attended physician, defibrillation by emergency responder, use of advanced airway management, call-to-response time, and
call-to-hospital arrival time.
¶
Adjusted for a predefined set of potential 13 confounders: above mentioned 11 confounders plus age and epinephrine administration.
no longer significant for 30-day CPC 1–2 (12.4% [81/652] vs. 9.8%
[63/646], P = 0.13).
4 Discussion
Using propensity-score matching analyses, this nationwide
population-based observational study analysed the data of a large
cohort of paediatric OHCAs from the All-Japan Utstein Registry
for 8 years. In unmatched cohorts, CC-CPR was associated with
decreased odds of 30-day favourable outcomes compared with conventional CPR. However, after propensity-score matching, CC-CPR
had similar neurologically intact survival to conventional CPR in
children aged 1–17 years with cardiac aetiology, initial shockable
rhythm, or ≥8 years compared with conventional CPR. Further,
we demonstrate that CC-CPR was equivalent to conventional CPR
for infants with cardiac aetiology or witnessed arrest. Therefore,
we propose that CC-CPR by bystanders may provide a reasonable
alternative to conventional CPR in certain paediatric OHCAs, and
may help to increase the rate of bystander CPR by reducing both
procedural complexity as well as barriers to bystander action [13].
Although differences in cardiac arrest aetiology between children and adults necessitate procedural differences in resuscitation
technique, no evidence exists identifying a precise age to initiate
adult CPR techniques [2]. According to the Guidelines 2000 for CPR
and emergency cardiovascular care (ECC) published by AHA with
ILCOR [1], an “adult” is defined as any individual ≥8 years of age
based largely on practical criteria and ease of teaching. Further, the
2005 AHA Guidelines for CPR and ECC recommended that adult
guidelines for the lay rescuer apply to victims approximately 8
years of age and older; for healthcare providers, adult guidelines
apply to post-pubescent victims (approximately 12–14 years of
age) [2]. In the 2010 AHA guidelines for CPR and ECC (as well as
in the 2015 AHA update), adult BLS guidelines apply during and
past puberty [3,4]. The findings in this paper suggest that the current adult BLS guidelines for the lay rescuer may extend to children
aged ≥8 years, and children aged 1–17 years with cardiac aetiology
of arrest or a shockable rhythm.
In the present investigation, conventional CPR was found to
be better in infants with cardiac arrest of non-cardiac origin (the
proportion among matched patients was 59% [1179/1994]) and
unwitnessed status (84% [1668/1994]), in children aged 1–17 years
with cardiac arrest of non-cardiac origin (67% [1795/2682]) and
non-shockable status (91% [2443/2682]), and in children aged 1–7
years (52% [1384/2682]), compared to CC-CPR in terms of 30-day
CPC 1–2 rate. Based on these results, the patients who should
receive conventional CPR are infants with unwitnessed status and
children aged 1–17 years with non-shockable status, regardless of
the aetiology of cardiac arrest.
Emergency dispatch centres in Japan have increasingly become
more active in relaying CPR instructions to citizens performing
CPR [15]. Interestingly, dispatcher-assisted instruction of CPR in
Japan was converted from conventional CPR to CC-CPR in 200618
before the AHA recommendation of CC-CPR in 2008 [13]. Critically
owing to these EMS efforts, the proportion of CC-CPR has increased
significantly, accounting for over 70% of all bystander CPR performed during the study period in both age groups (Supplementary
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
G Model
RESUS-7347; No. of Pages 9
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Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
7
Fig. 2. 30-day Outcomes by Survival and Good Neurological Outcome Following Out-of-Hospital Cardiac Arrest among 4676 Matched Children.
A, Patient numbers. B, Infants. C, Children aged 1–17 years. CPC, cerebral performance category; CPR, cardiopulmonary resuscitation. *Cochran-Armitage trend test was
performed.
Fig. 3. 30-day Outcomes in Matched Cohorts by Age and Subgroup.
A, Survival rate in infants. B, CPC 1–2 rate in infants. C, Survival rate in children aged 1–17 years. D, CPC 1–2 rate in children aged 1–17 years. CPC, cerebral performance
category; CPR, cardiopulmonary resuscitation.
Tables S1 and S2). Particularly, the prevalence of CC-CPR for infants
with OHCA may contribute to the increase of 30-day survival in
OHCA infants (Supplementary Tables S1). Although the proportion
of infants with witnessed arrest was minor (16.8% [478/2842]), the
Please cite this article in press as: Goto Y, et al. Conventional versus chest-compression-only cardiopulmonary resuscitation by
bystanders for children with out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.015
G Model
RESUS-7347; No. of Pages 9
8
ARTICLE IN PRESS
Y. Goto et al. / Resuscitation xxx (2017) xxx–xxx
present results indicate that CC-CPR was equivalent to conventional
CPR for infants with witnessed arrest; this finding demonstrates
that the advantages of hemodynamic maintenance by continuous
chest compression far surpass any disadvantages due to insufficient
blood oxygen saturation.
Based on the adjusted OR of CC-CPR for 30-day outcomes in
matched cohorts, we calculated estimated 30-day outcomes (Supplementary Table S3). If we only performed CC-CPR in all children
with OHCA, the rates of 30-day outcomes would be significantly
decreased in children aged 1–7 years (survival rate: from 13.4% to
8.4%, CPC 1–2 rate: from 4.5% to 2.0%, all P < 0.001); however, the
rates would not change in infants and children aged 8–17 years.
The results of the present investigation are consistent with
those from a study by Kitamura [14], which analysed an identical Japanese database from 2005 to 2007. Fukuda [16] evaluated
Japanese children aged 1–17 years with OHCA between 2011 and
2012, and demonstrated that CC-CPR had effects on 30-day CPC
1–2 similar to those obtained with conventional CPR, regardless
of arrest aetiology, witness status, or age subgroup. Interestingly,
these results are somewhat inconsistent with the present findings.
Unlike Fukuda’s study, we excluded children who were not treated
by EMS personnel because the accuracy of OHCA is not fully verified
before EMS arrival. Moreover, we accounted for several prehospital
cofounding variables including geographic region, because regional
disparities in prehospital care and in-hospital post-resuscitation
care are prominent in Japan [23,24]. As shown in Fig. 2-C, no significant differences in 30-day CPC 1–2 were found between two
types of bystander CPR in patients from 2011 to 2012, which was
consistent with Fukuda’s findings. Furthermore, the rate of 30-day
CPC 1–2 gradually improved in children receiving CC-CPR from
the 2007–2008 period to the 2013–2014 period. Possible explanations for these results include the nationwide dissemination of the
following recommendations based on the 2010 international CPR
guidelines update: (1) CC-CPR with high-quality assist by a dispatcher on the phone, (2) change from A-B-C to C-A-B sequence for
CPR, and (3) improvement of post-resuscitation care (e.g. targeted
temperature management).
Naim [8] demonstrated that conventional CPR was superior
to CC-CPR in infants with respect to neurologically intact survival. In the present investigation, conventional CPR in infants was
associated with an increased likelihood of favourable outcomes
compared with CC-CPR in a regression analytical model; this treatment superiority was only observed in cases with non-cardiac
aetiology or unwitnessed arrest after propensity-score matching.
This finding may be attributable to inherent differences between
EMS systems or post-cardiac arrest care.
This observational study has several potential limitations. First,
the actual aetiology of cardiac arrest was not fully verified. Some
infants may have had sudden infant death syndrome, a common
aetiology for arrest followed by trauma and respiratory disease
[25]. A nationwide school-based ECG screening program for cardiovascular diseases has been developed for all first, seventh, and
tenth graders since 1994 in Japan [26]. However, combined analyses of data for sudden cardiac death and/or OHCA and data from
the school-based screening program have not been performed. Second, although the duration of bystander CPR prior to EMS arrival
may have influenced the patient outcomes [27], our analysis could
not account for this issue. Third, owing to the retrospective nature
of the study, the data lacked sufficient detail required to perform
further risk adjustment for outcomes (e.g., comorbid diseases, location of arrest, CPR quality, and in-hospital medication). Finally,
caution must be exercised when generalizing these results to additional EMS systems, as a relatively infrequent use of epinephrine
(<5% in the present study) was observed, compared with prominent epinephrine use in the United States (65%) [10]. Therefore, an
adequately powered randomized controlled trial will be required
to determine the role of CC-CPR by bystanders for children with
OHCA.
5 Conclusions
Conventional CPR was associated with improved outcomes
compared to CC-CPR in the majority of the paediatric subgroups
following OHCA. CC-CPR by bystander was associated with similar neurologically intact survival to conventional CPR for children
with OHCA aged ≥8 years, for children aged 1–17 years with cardiac
aetiology or initial shockable rhythm, and for infants with cardiac
aetiology or witnessed arrest.
Funding sources
This work was supported by the Japan Society for the Promotion of Science (KAKENHI Grant Number 15K08543), which had no
role in the design and implementation of the study, analysis and
interpretation of the data, or approval of the manuscript.
Conflicts of interest
None.
Acknowledgement
We thank all the EMS personnel and participating physicians in
Japan and FDMA for their generous cooperation in establishing and
maintain the database.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.resuscitation.2017.
10.015.
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