Dr. Peter Antevy (Handtevy Minute) critiques the American Heart Association’s PALS 2020 change that recommends increasing ventilation to 20–30 breaths/min during pediatric cardiac arrest. He argues this risks raising intrathoracic pressure, reducing preload and cerebral perfusion, and causing cerebral vasoconstriction — potentially worsening outcomes. He cites a 2004 pig study (Atz/others) showing better survival with ~12 breaths/min versus 30, and criticizes the AHA reliance on a small (n=47) in-hospital pediatric observational study (high proportion congenital heart disease, many intubated) as insufficient for changing field practice. He notes ILCOR retained 10 breaths/min and urges AHA to re-evaluate.
Questions this video answers
20,000 children per year.
20–30 breaths per minute.
10 breaths per minute.
2004 pig study by Tom (Tom Afterharty) and Keith Lurie comparing ~12 vs 30 breaths per minute.
Higher-rate (30/min) ventilation associated with lower systolic blood pressure, decreased cerebral perfusion pressure, and poor survival/neuro-intact survival.
Chapters
Hey everyone, this is Dr. Peter Gentevi with another edition of the Entebbe Minute. And today I want to talk about the PALS 2020 guidelines that were recently released. What's important here is that 20,000 children every year die from pediatric cardiac arrest. And we know that those who die out of hospital have a very poor outcome and, and their neurologic intact survival has been low for decades now. Why hasn't that changed? Well, the guidelines attempted this year to make a change and what they did was they increased the ventilation rate from 10 breaths per minute all the way to 20 to 30 breaths per minute in an attempt to finally make a change with outcomes. However, I have a word of caution here and I'm concerned about that specific recommendation. Now why is that? Lets take a look at what happens when you ventilate somebody. It's important to get those first couple of big breaths in. It opens the lungs and it allows blood to flow through the lungs and start to get the circuit moving. But you also have to understand that the blood has to flow into the brain and out of the brain. And then of course, the heart, which is stuck in the middle of those two, cannot be squeezed down too tightly. So if you're overzealous with ventilation or the pressures are too high in the thorax, what happens is that you diminish preload and you also inhibit blood from returning from the brain. Furthermore, hyperventilation will cause vasoconstriction in the brain. So we now have three big reasons why not to hyperventilate children in cardiac arrest. And even though hyperventilation may give you a higher oxygenation level, more importantly is the flow from the heart to the brain and back into and in through the lungs. And so that flow is, I think what they're missing here with these new recommendations to where do we have this data from on how to ventilate children at 10 breaths per minute? Well, unfortunately we only have pig studies. And in 2004, Tom Afterharty and Keith Lurie published a fantastic paper on how fast we should ventilate pigs. And it turns out that if you ventilated those pigs at 12 breasts per minute as compared to 30 breasts per minute, those pigs tended to live. A majority of cases, the pigs who got ventilated at 30 breaths per minute, not only did they have a lower systolic blood pressure, not only did they have a decreased cerebral perfusion pressure, but almost across the board those pigs all died and did not have any neuro intact survival. So in 2005, the recommendations for across the board, 10 breaths per minute was made and we agree with that. So the 2020 guidelines used a single paper to make this change to the guidelines. And the paper was unfortunately, an in Hospital pediatric ICU study. It was an observational study with only 47 children. Now, when you look at the data, you can see here on the screen that 60% of those children had a pre existing condition of congenital heart disease. Furthermore, all of these children were intubated and we would have to presume that their fluid management was maximized. Now, if you look at the next table here on the screen, you can see that the presenting rhythm for these children in this ICU was bradycardia with poor perfusion. And when you look at the eight children in the study who presented an asystole, all of those patients died. So how do we translate that to what we do in the field out of hospital cardiac arrest and pediatrics? When we roll up, it's asystole pea. Those children do not have an airway, their fluid status is not maximized, and clearly they do not have bradycardia with poor perfusion as an initial rhythm. So I would call on the American Heart association and the writing group to really re evaluate this recommendation and understand the physiology of cerebral perfusion pressure, understanding the importance of not elevating intrathoracic pressure because of the effects that it'll have on the heart and unfortunately the detrimental effect it'll have on children around this country. Now, I will end by saying that the international consensus of the resuscitation guidelines, ILCOR did stick with the 10 breaths per minute, which I'm happy to hear they did not move to the 20 to 30 breaths per minute like the American Heart association did. This has been Dr. Peter Hantevi for another edition of the Hantevi Minute. Thank you.
