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Are PALS Ventilation Rates Too Slow?

September 11, 2019

Written by Clay Smith

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For pediatric in-hospital arrest, ventilation exceeding guideline recommendations was common and was associated with improved survival to discharge.

Why does this matter?
PALS/BLS recommends 30:2 single rescuer compression to ventilation ratio and 15:2 with 2 rescuers. They recommend 10 breaths per minute with advanced airways. Excessive ventilation may impede venous return and is to be avoided (Class III, level C AHA recommendation). On the other hand, ten breaths per minute isn’t physiologic for children either. What if ventilation wasn’t excessive but was faster than the current AHA standards?

Emotional bagging…is good?
This was a multi-center secondary retrospective analysis of 47 pediatric in-hospital arrest patients using data from a prospective observational study. They deemed 10 +/- 2 breaths per minute to be guideline concordant; a “fast” RR was considered ≥30 if under age 1, ≥25 for all other pediatric age groups. None of the patients had guideline concordant ventilation; median RR was 29.8 breaths/minute. After adjusting for confounders, a “fast” ventilation rate was associated with improved survival to discharge compared to slower ventilations—which were still faster than guideline recommendations (OR 4.73, p = 0.029). Although I don’t see changing PALS/BLS recommendations on the basis of this retrospective study, it does make me wonder if the guideline recommendations are a bit slow. We know excessive hyperventilation is harmful. While we have to keep the RR in check, 10-12 breaths/minute may be too slow for children.

Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019 Aug 1. doi: 10.1097/CCM.0000000000003898. [Epub ahead of print]

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Reviewed by Thomas Davis

What are your thoughts?